Inspection Reports for Carriage Hill Retirement
1203 Roundtree Drive, VA, 24523
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
48.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
433% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
71 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 28, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-03 regarding allegations in the area of resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, a violation unrelated to the complaint was identified involving improper storage of medications on the medication cart.
Complaint Details
Complaint was received on 2025-07-03 regarding resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure a medicine cabinet, container, or compartment was used for storage of medications and dietary supplements prescribed for residents when administered by the facility. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Medication Aide (RMA) | Staff person 1 identified as the assigned RMA to the A-Hall Medication cart and involved in the medication storage deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2025-06-30 regarding allegations in the area of resident care and related services.
Findings
The investigation found violations related to failure to ensure skilled nursing treatments were met by licensed nurses or agencies, failure to keep resident records current and retained, and failure to prepare and serve prescribed diets according to physician orders. Violations were substantiated and corrective actions were required.
Complaint Details
The complaint was substantiated. Evidence showed missed skilled nursing wound care visits due to authorization delays and lack of facility supplies, as well as failures in record keeping and diet preparation.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure residents' skilled nursing treatments were met by licensed nurses or contractual agreements, resulting in missed wound care visits and lack of documentation. |
| Facility failed to ensure all resident records were kept current and retained at the facility. |
| Facility failed to ensure prescribed diets were prepared and served according to physician or prescriber orders, serving a mechanical soft diet instead of pureed consistency. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-30 regarding allegations related to resident care and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, including failure to complete a fall risk rating after a fall and incomplete medication administration records.
Complaint Details
Complaint was received on 2025-06-30 regarding resident care and related services and additional requirements for adults with serious cognitive impairments. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that a fall risk rating was completed after a fall for a resident assessed as assisted living level of care. |
| Facility failed to ensure that all required information was included on medication administration records (MARs), including missing staff initials and unclear dash symbol documentation. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint investigation |
| Director of Resident Services | Named in plan of correction related to fall risk assessment deficiency |
Inspection Report
Monitoring
Deficiencies: 6
Jul 2, 2025
Visit Reason
The inspection was a monitoring visit conducted on July 2, 2025, following a self-reported incident received on June 28, 2025, regarding allegations in the area of resident care and related services.
Findings
The inspection findings supported the self-report of non-compliance with multiple violations issued related to failure to report major incidents timely, inadequate administration and oversight by the facility administrator, failure to ensure resident health and safety, and deficiencies in medication management and documentation.
Deficiencies (6)
| Description |
|---|
| The facility failed to report all required information to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| The administrator failed to ensure responsibility for the general administration and management of the facility and failed to oversee the day-to-day operation of the facility. |
| The facility failed to assume responsibility for the health, safety, and well-being of the residents, including inadequate review and management of residents with psychiatric diagnoses and medication adherence. |
| The facility failed to implement its written plan for medication management to ensure timely filling of prescriptions and accurate transcription of medication orders to medication administration records (MARs). |
| The facility failed to ensure medical procedures or treatments ordered by a physician or prescriber were provided according to instructions, documented, and maintained in the resident's record. |
| The facility failed to ensure that all required information was included on medication administration records (MARs), including staff initials and documentation of medication administration. |
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Number of closed inspections during current licensure period: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 18, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-10 regarding allegations related to building and grounds.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint related to building and grounds; investigation did not substantiate non-compliance.
Report Facts
Number of interviews conducted with staff: 6
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Deficiencies: 6
May 29, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 05/20/2025 and 06/05/2025 regarding allegations in the areas of resident care and related services and building and grounds.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in the area of building and grounds. Multiple violations were identified related to individualized service plans, medication management, medication administration, medication availability, and facility furnishings.
Complaint Details
The complaint investigation was substantiated in part; violations related to building and grounds were found. Some allegations were not supported by evidence.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or legal representative. |
| Facility failed to implement its medication management plan (MMP) properly, including failure to notify physicians of medication refusals. |
| Medications were not administered in accordance with physician's orders; documentation errors and medication unavailability were noted. |
| Medication administration record (MAR) did not include documentation of medication errors or omissions. |
| Medications ordered for PRN administration were not available, properly labeled, or properly stored at the facility. |
| Bedrooms failed to contain a sturdy chair for each resident. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Deficiencies: 5
May 9, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-05-06 regarding allegations related to resident care and related services at Carriage Hill Retirement.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified, primarily concerning medication management, including failure to ensure timely medication delivery, proper administration, and accurate medication records for a resident.
Complaint Details
Complaint was related to allegations in resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (5)
| Description |
|---|
| Facility failed to assume responsibility for the health, safety, and well-being of residents, specifically regarding delayed delivery and improper documentation of Clozapine medication administration. |
| Facility failed to ensure that the health care service needs of the resident were met, including failure to obtain required lab work (CBC) timely. |
| Facility failed to implement its medication management plan to ensure prescription medications were filled and refilled timely to avoid missed dosages. |
| Facility failed to ensure medications were administered in accordance with physician's orders, including missed doses and administration without proper orders. |
| Medication administration records did not include medication errors or omissions and lacked proper documentation of date, time, and staff initials for medication administration. |
Report Facts
Inspection dates: 3
Resident records reviewed: 1
Staff interviews conducted: 7
Medication doses not delivered: 28
Missed medication administration dates: 6
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Apr 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 03/28/2025 and 03/31/2025 regarding allegations in the area of resident care and related services.
Findings
The investigation supported some, but not all, of the allegations. The facility was found non-compliant with the requirement for two-hour rounding of residents who are unable to use the signaling device system, as documentation of such rounds was not provided for several days.
Complaint Details
The complaint was substantiated in part; evidence showed non-compliance with two-hour rounding requirements for residents unable to use signaling devices.
Deficiencies (1)
| Description |
|---|
| Failure to ensure two-hour rounding of residents with an inability to use the signaling device system, including proper documentation of rounds. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 71
Deficiencies: 21
Apr 29, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility license renewal.
Findings
The inspection identified multiple areas of non-compliance including staff training deficiencies, incomplete or inaccurate resident records and service plans, medication management issues, improper storage of hazardous materials, building maintenance concerns, and failure to conduct required emergency preparedness reviews. Violations were documented and a plan of correction was requested.
Deficiencies (21)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of training annually. |
| Facility failed to ensure at least two hours of annual training focused on infection control and prevention and four hours on mental impairments when applicable. |
| Facility failed to meet requirements for private duty personnel providing direct care or companion services. |
| Facility failed to maintain personal and social data including emergency contacts in staff records. |
| Facility failed to provide annual refresher training for direct care staff when aggressive residents are in care. |
| Uniform assessment instrument (UAI) was not completed or accurate prior to admission, annually, or with significant change. |
| Individualized service plans (ISPs) were not reviewed and updated as needed for significant changes in resident condition. |
| Rights and responsibilities of residents were not reviewed annually with staff and documented. |
| Facility failed to prepare and serve diets according to physician orders. |
| Facility failed to ensure dietitian or nutritionist oversight at least every six months for residents with special diets. |
| Facility failed to implement medication management plan including proper labeling and discard dates on medication containers. |
| Resident records lacked signed physician orders or proper chronological organization of orders. |
| Residents were permitted to keep medications without physician orders or contrary to assessment indicating inability to self-administer. |
| Medications were not administered according to physician orders, including discontinued medications being given and insulin administered when blood sugar levels indicated to hold. |
| Medication administration records (MARs) lacked names, signatures, and initials of all staff administering medications. |
| Cleaning supplies and hazardous materials were stored in unlocked and unattended areas. |
| Interior of buildings was not maintained in good repair and cleanliness, including damaged flooring and unclean toilets. |
| Facility buildings were not well-ventilated and had foul, stale, and musty odors. |
| Facility failed to ensure rounds every two hours for residents unable to use signaling devices with proper documentation. |
| Facility failed to have annual fire inspection reports retained and up to date. |
| Facility failed to implement semi-annual review of emergency preparedness and response plan with documentation. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 11
Number of staff records reviewed: 3
Number of resident interviews: 4
Number of staff interviews: 5
Medication administration record (MAR) review dates: 202504
Training year periods: Jun 16, 2023
Medication discard timeframe: 28
Fire inspection date: Jan 4, 2024
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the Virginia Department of Social Services Division of Licensing on 04/17/2025 and 04/21/2025 regarding allegations related to resident care and related services at the assisted living facility.
Findings
The investigation found multiple violations including failure to report a major incident within 24 hours, failure to complete the uniform assessment instrument within required timeframes, and failure to assume responsibility for the health, safety, and well-being of residents. The facility did not report a sexual incident involving two residents and failed to ensure proper assessment and placement documentation.
Complaint Details
The complaint was substantiated. Evidence supported allegations of non-compliance with standards and law related to resident care and safety. The incident involved a male resident found naked in a female resident's bed, with allegations of sexual contact. The resident was subsequently arrested and charged with aggravated sexual battery.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure the uniform assessment instrument (UAI) was completed within 90 days prior to admission as required. |
| Facility failed to assume responsibility for the health, safety, and well-being of the residents, including inadequate supervision and response to a sexual incident between residents. |
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Date of resident admission: Apr 16, 2025
Date of incident: Apr 17, 2025
Date of resident arrest: Apr 20, 2025
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Mar 28, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-03-19 regarding allegations in the area of resident care and related services at Carriage Hill Retirement.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, including failure to complete individualized service plans accurately and failure to administer medications according to physician instructions.
Complaint Details
Complaint was received on 2025-03-19 regarding resident care and related services. The evidence gathered did not support the allegation of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) was completed accurately within 30 days after admission, reflecting resident needs based on assessments and interviews. |
| Facility failed to ensure medications were administered according to the physician's or other prescriber's instructions. |
Report Facts
Residents present: 71
Resident records reviewed: 1
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Feb 5, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-23 regarding allegations in the areas of resident care and related services and buildings and grounds.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt of the inspection summary.
Complaint Details
Complaint related inspection with allegations in resident care and related services and buildings and grounds; evidence did not support the allegations.
Report Facts
Number of residents present: 60
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 4
Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2025-02-04 regarding allegations in the area of resident care and related services.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified during the inspection. These violations involved failures in written communication among staff, incomplete individualized service plans, unmet healthcare service needs, and medication administration errors.
Complaint Details
Complaint was received on 2025-02-04 regarding resident care and related services. The evidence gathered did not support the allegation of non-compliance with standards or law.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a method of written communication was utilized to keep direct care staff informed of significant resident issues, including complaints and incidents. |
| Facility failed to complete comprehensive individualized service plans (ISP) within 30 days after admission, lacking documentation of identified needs and services for effective communication and behavioral monitoring. |
| Facility failed to ensure that the health care service needs of a resident were met, including failure to obtain required medication lab levels. |
| Facility failed to ensure medications were administered in accordance with physician orders, including missed documentation of prescribed medication and incorrect administration times. |
Report Facts
Number of residents present: 60
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Medication dosage: 750
Medication administration errors: 2
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Jan 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-01-21 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related inspection regarding allegations in resident care and related services; the complaint was not substantiated.
Report Facts
Residents present: 60
Resident records reviewed: 2
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 10
Jan 21, 2025
Visit Reason
The inspection was conducted due to a complaint received on 2024-12-20 regarding allegations in the areas of admission, retention and discharge of residents, staffing and supervision, and resident care and related services.
Findings
The investigation supported the allegations of non-compliance with multiple standards, resulting in violations issued. Deficiencies were found in areas including cognitive impairment assessments, staffing schedules, fall risk assessments, individualized service plans, documentation of changes in resident condition, personal care, medication management, medication administration, and use of PRN medications.
Complaint Details
The complaint investigation was substantiated with violations issued based on evidence gathered during the inspection on 2025-01-21. The complaint involved admission, retention and discharge of residents, staffing and supervision, and resident care and related services.
Deficiencies (10)
| Description |
|---|
| Failed to ensure prior to admission to memory care that resident was assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Failed to maintain a written work schedule including names, job classifications, and indication of staff in charge each shift. |
| Failed to review and update fall risk rating after a fall. |
| Failed to review and update individualized service plans for significant change in resident condition. |
| Failed to document change in resident condition or functioning in resident record. |
| Failed to provide personal assistance and care including bathing at least twice weekly as needed. |
| Failed to implement medication management plan to ensure timely filling and refilling of medications to avoid missed dosages. |
| Failed to administer medications in accordance with physician or prescriber instructions. |
| Failed to ensure all required information was documented on resident medication administration records (MARs), including proper identification of agency staff administering medications. |
| Failed to ensure use of PRN medications was properly ordered with detailed instructions and administered only when resident capable or by licensed personnel. |
Report Facts
Number of residents present: 60
Number of resident records reviewed: 9
Number of staff records reviewed: 0
Number of resident interviews: 2
Number of staff interviews: 2
Plan of correction due dates: Mar 1, 2025
Plan of correction due dates: Mar 15, 2025
Plan of correction due dates: Feb 28, 2025
Plan of correction due dates: Feb 14, 2025
Plan of correction due dates: Feb 10, 2025
Inspection Report
Monitoring
Census: 60
Deficiencies: 8
Jan 21, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with resident care, medication management, physical plant, and related services standards.
Findings
The inspection found multiple violations related to medication management including improper medication storage, failure to document medication administration correctly, and failure to follow physician orders. Additional deficiencies included unsecured hazardous materials and maintenance issues such as water leaks and cleanliness concerns.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure medication containers had required information including expiration or discard dates. |
| Schedule II drugs were not stored in a separate locked compartment; narcotic drawer lock was inoperable. |
| Resident was permitted to keep medication in room without proper authorization per assessment instrument. |
| Medications were not administered according to physician orders; discrepancies in dosage and discontinued medications administered. |
| Medical procedures ordered by physician were not provided or documented as required. |
| Required information was missing on resident medication administration records (MARs). |
| Cleaning supplies and hazardous materials were stored in an unlocked area. |
| Interior of buildings was not maintained in good repair and cleanliness; water puddle and black substance observed in resident bathroom. |
Report Facts
Number of residents present: 60
Number of resident records reviewed: 11
Number of staff interviews: 3
Number of resident interviews: 2
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Nov 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-06 regarding allegations in the areas of personnel and resident care and related services.
Findings
The investigation found violations related to failure to provide personal assistance and care with bathing as needed, failure to administer medications according to physician orders, and failure to document medication administration properly. Violations were substantiated and corrective plans were required.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting allegations of non-compliance with standards and laws related to personnel and resident care.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure personal assistance and care with bathing at least twice a week as needed or desired. |
| Facility failed to ensure medications were administered in accordance with physician or prescriber instructions. |
| Facility failed to document all medications administered to residents on the medication administration record (MAR). |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 10
Number of staff records reviewed: 0
Number of resident interviews: 4
Number of staff interviews: 2
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 4
Nov 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-10-22 regarding allegations in the areas of resident care and related services.
Findings
The investigation found multiple violations including failure to update individualized service plans for significant changes in resident conditions, failure to prepare and serve diets according to physician orders, failure to maintain a current diet manual, and failure to administer medications in accordance with physician instructions.
Complaint Details
The complaint was substantiated as the evidence supported allegations of non-compliance with standards and laws related to resident care, diet management, and medication administration.
Deficiencies (4)
| Description |
|---|
| Failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for significant changes in resident conditions. |
| Failed to ensure prescribed diets were prepared and served according to physician or prescriber orders. |
| Failed to maintain a current diet manual containing acceptable practices and standards for nutrition readily available to food preparation personnel. |
| Failed to ensure medications were administered in accordance with physician instructions, specifically oxygen administration for a resident. |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 2
Number of staff interviews conducted: 4
Number of resident interviews conducted: 2
Inspection Report
Monitoring
Census: 63
Deficiencies: 4
Nov 20, 2024
Visit Reason
The inspection was a monitoring visit to assess compliance with resident care, buildings, and grounds standards at the assisted living facility.
Findings
The inspection found multiple violations including failure to post a current dated menu, improper storage of schedule II drugs, unlocked storage of hazardous cleaning supplies, and maintenance issues such as water puddles, missing light covers, damaged fence, and flaking vents.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that the menu for the current week was dated and posted in an area conspicuous to residents. |
| Facility failed to ensure that schedule II drugs and other drugs subject to abuse were kept in a separate locked storage compartment. |
| Facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. |
| Facility failed to ensure the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish. |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Nov 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-11-04 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting was planned to review the findings.
Complaint Details
Complaint related to additional requirements for facilities that care for adults with serious cognitive impairments; the complaint was not substantiated.
Report Facts
Number of residents present: 63
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Nov 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-11-18 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law. The inspection summary will be posted publicly within five business days.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2024-11-18 regarding allegations in the area of additional requirements for facilities that care for adults with serious cognitive impairments. The evidence gathered did not support the allegation of non-compliance.
Report Facts
Number of residents present: 63
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Nov 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-11-11 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation found non-compliance with regulations requiring at least two direct care staff members to be awake and on duty at all times in the special care unit during night hours when 22 or fewer residents are present. Violations were issued based on evidence including staff timesheets and interviews.
Complaint Details
Complaint related: Yes. The evidence supported the allegation of non-compliance with staffing requirements in the memory care unit during night hours when 22 or fewer residents were present.
Deficiencies (1)
| Description |
|---|
| Failed to ensure during night hours when 22 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit. |
Report Facts
Number of residents present at inspection: 63
Memory care unit census: 20
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Nov 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-31 regarding allegations related to resident care and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation supported the allegation of non-compliance with standards and violations were issued. Deficiencies included insufficient direct care staff during night hours in the memory care unit, failure to maintain written communication logs regarding resident incidents, and inadequate documentation of required resident rounds for those unable to use signaling devices.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, confirming violations related to staffing, communication, and resident monitoring.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure at least two direct care staff members were awake and on duty during night hours in the memory care unit when 22 or fewer residents were present. |
| Facility failed to ensure a method of written communication was utilized to keep direct care staff informed of significant happenings, including complaints and incidents. |
| Facility failed to ensure direct care staff made rounds at least every two hours for residents unable to use signaling devices, and failed to document these rounds properly. |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 5
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 6
Oct 4, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-03 regarding allegations related to staffing and supervision and resident care and related services at Carriage Hill Retirement.
Findings
The investigation supported the allegations of non-compliance with applicable standards and laws, resulting in violations issued. Deficiencies were found in posting the current on-site person in charge, medication management, medication administration, documentation on medication administration records (MAR), and resident rounds documentation.
Complaint Details
Complaint was substantiated with violations issued related to staffing and supervision and resident care and related services.
Deficiencies (6)
| Description |
|---|
| Facility failed to post the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to implement its medication management plan, including narcotic inventory counts and discrepancy reporting. |
| Facility failed to ensure medications were administered according to physician's orders, including missed doses and improper documentation. |
| Facility failed to document all medications administered on the medication administration record (MAR), including over-the-counter medications and dietary supplements. |
| Facility failed to include date, time, and initials of staff administering medications on the MAR. |
| Facility failed to ensure direct care staff made rounds at least every two hours for residents unable to use signaling devices, and failed to document these rounds properly. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 6
Number of staff interviews conducted: 4
Medication doses received: 120
Medication doses counted: 117
Hydrocodone tablets remaining: 7
Blood sugar reading: 410
Emergency room arrival time: 2024
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Oct 1, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 09/27/2024 regarding allegations in the areas of personnel and resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, violations unrelated to the complaint were identified, specifically a failure to implement the facility's medication management plan, including inadequate documentation of medication refusals and medication supply issues.
Complaint Details
Complaint was received on 09/27/2024 regarding personnel and resident care. The evidence gathered did not support the allegation of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure implementation of its medication management plan, including lack of documentation of medication refusals and failure to maintain adequate medication supply. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews: 2
Number of staff interviews: 2
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Sep 23, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the Virginia Department of Social Services Division of Licensing on 09/23/2024 regarding allegations in the areas of resident care and related services and buildings and grounds.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found related to resident care and related services, including failure to meet residents' health care service needs and failure to administer medications according to physician orders.
Complaint Details
The complaint was substantiated in part; evidence supported some allegations related to resident care and medication administration. A violation notice was issued, and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met, as evidenced by a resident not receiving a prescribed dental infection medication and lack of referral to a dentist. |
| The facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, as evidenced by a resident not receiving prescribed amoxicillin medication. |
Report Facts
Residents present: 57
Resident records reviewed: 2
Resident interviews conducted: 5
Staff interviews conducted: 5
Medication training timeframe: 21
Improvement plan duration: 30
Inspection Report
Monitoring
Census: 57
Deficiencies: 2
Sep 19, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and building standards at the assisted living facility.
Findings
The inspection found non-compliance with medication administration standards, including failure to administer medications as prescribed and improper use of PRN medications. Violations were documented and corrective actions were required.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
| The facility failed to ensure that the use of PRN (as needed) medications is prohibited unless specific conditions are met, including detailed medication orders with symptoms, dosage, and directions. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 7
Number of staff records reviewed: 0
Number of resident interviews: 2
Number of staff interviews: 4
Physician order date: 28
Medication administration discrepancy: 25
Improvement plan duration: 30
Inspection Report
Monitoring
Census: 60
Deficiencies: 5
Jul 25, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and building standards at Carriage Hill Retirement.
Findings
The inspection found multiple violations related to medication management, including failure to prevent use of outdated medications, unlocked medication carts, improper storage and handling of medications, and failure to ensure medications remained in pharmacy-issued containers until administered.
Deficiencies (5)
| Description |
|---|
| Failed to implement medication management plan to prevent use of outdated, damaged, or contaminated medications. |
| Failed to ensure medication storage cabinets or carts were locked. |
| Failed to ensure medication administration staff kept keys to medication storage on their person. |
| Failed to ensure residents capable of self-administering medications were permitted to keep medications in an out-of-sight place in their rooms. |
| Failed to ensure medications remained in pharmacy-issued containers with labels until administered. |
Report Facts
Number of residents present: 60
Number of resident records reviewed: 4
Number of staff records reviewed: 1
Number of resident interviews: 2
Number of staff interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person 4 | Registered Medication Aide (RMA) | Named in findings related to unlocked medication cart and improper medication handling; employment terminated on 7/25/24. |
| Jennifer Stokes | Licensing Inspector | Conducted the inspection and documented findings. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-10 regarding allegations in the area of resident care and related services at Carriage Hill Retirement.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified regarding the facility's failure to ensure a method of written communication to keep direct care staff informed of significant resident incidents and complaints.
Complaint Details
Complaint related: Yes. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure a method of written communication was utilized to keep 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. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Jul 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-09 regarding allegations of physical abuse and concerns in personnel and resident care related services at the facility.
Findings
The investigation did not substantiate the complaint allegations of non-compliance with standards or law. However, violations unrelated to the complaint were identified, including failure to report suspected abuse to the local Adult Protective Services Agency as required by law.
Complaint Details
The complaint alleged physical abuse of a resident during a shower by a staff person. Evidence showed the staff person had been restricted from caring for the resident during the investigation but later provided care again. The facility did not report the suspected abuse to the local Adult Protective Services Agency as required by law. The complaint was not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to report suspected abuse, neglect, or exploitation of residents to the local Adult Protective Services Agency as required by § 63.2-1606 of the Code of Virginia. |
Report Facts
Number of residents present: 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
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-06-07 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint related to additional requirements for facilities that care for adults with serious cognitive impairments; the complaint was not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as the current inspector conducting the complaint investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-06-08 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings.
Complaint Details
Complaint related inspection with allegations in resident care and related services; the complaint was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 22, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-05-06 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related to resident care and related services; the allegation was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 22, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-05-06 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint was received on 2024-05-06 regarding resident care and related services; the allegations were not substantiated.
Inspection Report
Monitoring
Deficiencies: 0
May 22, 2024
Visit Reason
The inspection was a monitoring visit conducted on May 22, 2024, to review compliance with resident care, accommodations, and building standards.
Findings
The inspection found no violations with applicable standards or laws during the monitoring visit.
Inspection Report
Renewal
Census: 50
Deficiencies: 3
May 22, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to medication administration and staff criminal history record reports. The facility was given the opportunity to submit a plan of correction to address these violations.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure the use of PRN medications is prohibited unless specific conditions are met, including detailed medication orders with symptoms indicating use. |
| The facility failed to ensure that criminal history record reports were obtained on or prior to the 30th day of employment for each employee. |
| The facility failed to ensure that an employee has not been convicted of any barrier crimes when a criminal history record was requested. |
Report Facts
Number of residents present: 50
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
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 19, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-04-17 regarding allegations related to buildings and grounds at the facility.
Findings
The investigation did not substantiate the complaint allegations; however, a non-complaint related violation was identified regarding the lack of a functioning signaling device accessible to a resident in their bedroom and bathroom. The resident was relocated to a room with a fully functional call light system, and a plan of correction was implemented.
Complaint Details
Complaint was received on 2024-04-17 regarding buildings and grounds. The evidence gathered did not support the allegations of non-compliance related to the complaint.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a signaling device that is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts direct care staff that the resident needs assistance. |
Inspection Report
Monitoring
Deficiencies: 0
Mar 12, 2024
Visit Reason
The inspection was a monitoring visit conducted on March 12, 2024, to review compliance with resident care, related services, buildings, and grounds standards.
Findings
The inspection found no violations of applicable standards or laws during the visit. The inspection summary will be posted publicly within five business days.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 9, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-02-05 regarding allegations in the areas of personnel and resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings.
Complaint Details
Complaint related to allegations in personnel and resident care and related services; the complaint was not substantiated.
Inspection Report
Monitoring
Deficiencies: 0
Feb 9, 2024
Visit Reason
The inspection was a monitoring visit conducted on February 9, 2024, following a self-reported incident received on February 5, 2024, regarding allegations in the area of resident care and related services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting was planned to review the findings.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-05 regarding allegations in the area of resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified involving failure to report a major incident to the regional licensing office within 24 hours.
Complaint Details
Complaint related to resident care and related services received on 2024-01-05; evidence did not support allegations of non-compliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure reporting to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
Report Facts
Date of incident: Dec 4, 2023
Inspection duration: 39
Plan of Correction submission timeframe: 5
Review request timeframe: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-12-22 regarding allegations in the area of resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, specifically a failure to ensure medications were administered according to physician or prescriber instructions.
Complaint Details
Complaint was received on 2023-12-22 regarding resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Inspection dates: 2
Medication tablets discrepancy: 2
Plan of correction deadline: 2024
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-17 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related inspection; the allegations were not substantiated as the evidence did not support non-compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 29, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-11-28 regarding allegations in the areas of resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint received on 2023-11-28 regarding resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments; allegations were not substantiated.
Inspection Report
Monitoring
Deficiencies: 0
Nov 29, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations with applicable standards or laws. The inspection summary will be posted publicly within five business days.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 9, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-07-18 regarding allegations in the areas of personnel, buildings and grounds, and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint received on 2023-07-18 regarding personnel, buildings and grounds, and additional requirements for facilities that care for adults with serious cognitive impairments. The allegations were not substantiated.
Inspection Report
Monitoring
Deficiencies: 1
Aug 9, 2023
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws related to administration, personnel, resident care, and additional requirements for adults with serious cognitive impairments.
Findings
The inspection found non-compliance with medication administration standards, specifically that medications were not administered according to physician orders, with documentation errors noted in the medication administration record for a resident receiving insulin.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician or prescriber instructions, including improper documentation and administration of Humalog insulin for resident 1. |
Report Facts
Previous citations: 3
Training hours: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the monitoring inspection. |
| DON/Administrator | Reviewed resident 1 file and medication list on the day of inspection and completed staff training related to medication administration violations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 16, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-05-15 regarding allegations in the areas of personnel, staffing & supervision, and resident care & related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint received on 2023-05-15 regarding personnel, staffing & supervision, and resident care & related services. The allegations were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 1
May 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-03-20 regarding allegations in personnel, resident care and related services, and buildings and grounds.
Findings
The investigation found some areas of non-compliance with standards or law related to the complaint. A violation notice was issued for failure to ensure cleaning supplies were stored in a locked area, with evidence including a bottle of germicidal bleach left unsecured at the nursing station.
Complaint Details
Complaint was received by VDSS Division of Licensing on 03/20/2023 regarding allegations in personnel, resident care and related services, and buildings and grounds. The evidence supported some, but not all, allegations of non-compliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that cleaning supplies were stored in a locked area. |
Report Facts
Previous citations: 4
Plan of correction completion date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as the current inspector conducting the complaint investigation. |
Inspection Report
Monitoring
Census: 63
Deficiencies: 5
May 16, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations including insufficient cognitive impairment training for staff, incomplete resident uniform assessment instruments, missing 'No Smoking-Oxygen in Use' signage, furnishings not maintained in good repair, and lack of semi-annual review of emergency preparedness plans.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure direct care staff received at least 10 hours of training in cognitive impairment within four months of employment. |
| Facility failed to ensure private pay uniform assessment instruments (UAI) were completed as required. |
| Facility failed to post a 'No Smoking-Oxygen in Use' sign in any room where oxygen is in use. |
| Facility failed to ensure all furnishings were maintained in good repair, including a loose and cracked bed footboard. |
| Facility failed to ensure there was a semi-annual review on its emergency preparedness and response plan for all residents. |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 4
Number of staff interviews conducted: 3
Training hours for staff 1: 8.75
Training hours for staff 3: 5
Inspection Report
Monitoring
Deficiencies: 14
Mar 8, 2023
Visit Reason
An unannounced monitoring inspection was conducted to determine whether the provider had corrected or was in the process of correcting previously cited violations in the areas of administration, personnel, resident care, and additional requirements for adults with serious cognitive impairments.
Findings
The inspection found the provider demonstrated noncompliance with standards not identified in the plan of correction, including deficiencies in resident placement documentation, staff orientation and training, medication management, staff record completeness, medication administration, storage of hazardous materials, and facility ventilation.
Deficiencies (14)
| Description |
|---|
| Failed to ensure written determination for placement in special care unit for residents with serious cognitive impairment. |
| Failed to ensure orientation and training for new employees occurred within first seven working days. |
| Failed to ensure all required information was included in staff records. |
| Failed to ensure staff submitted tuberculosis risk assessment results prior to first day of work. |
| Failed to ensure individualized service plan was signed and dated by licensee and resident or legal representative. |
| Failed to ensure medication management plan was implemented to prevent use of outdated, damaged, or contaminated medications. |
| Failed to ensure medication cart keys were kept on person by responsible individuals. |
| Failed to ensure residents permitted to keep own medication in out-of-sight place only if capable of self-administration per assessment. |
| Failed to ensure medications remained in pharmacy issued container with prescription label until administered. |
| Failed to ensure medications were administered according to physician instructions and nursing standards. |
| Failed to ensure medical procedures and treatments ordered by physician were provided and documented. |
| Failed to ensure use of PRN medications included required physician orders with symptoms, dosage, and timing. |
| Failed to ensure cleaning supplies and hazardous materials were stored in locked areas. |
| Failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. |
Report Facts
Inspection dates: Inspection conducted on March 8, 2023 and March 14, 2023
Medication disposal timeframe: 28
Frequency of environmental rounds: 5
Medication administration times: 8
Inspection Report
Monitoring
Deficiencies: 6
Jan 17, 2023
Visit Reason
A non-mandated monitoring inspection was conducted as a probation inspection indicated in a special order issued on 06/17/2022 and a denial inspection indicated in a notice of intent issued on 09/10/2022.
Findings
The inspection found multiple violations including failure to provide personal assistance such as bathing, medication management deficiencies, improper storage of hazardous materials, and poor maintenance and cleanliness of the facility. Several standards were previously cited and remain uncorrected.
Deficiencies (6)
| Description |
|---|
| Failed to ensure personal assistance and care were provided to each resident, including bathing at least twice per week. |
| Failed to implement medication management plan ensuring accurate counts of controlled substances when medication administration staff changes. |
| Failed to ensure a resident capable of self-administering medication may keep medication in an out-of-sight place in their room. |
| Failed to ensure medication was in pharmacy-issued container with prescription or direction label attached. |
| Failed to ensure cleaning supplies and hazardous materials were stored in a locked area. |
| Failed to ensure interior and exterior of all buildings were maintained in good repair and kept clean. |
Report Facts
Refusal dates for bathing: 4
Medication count discrepancy: 1
Medication pass observations frequency: 6
Room sweep frequency: 4
Inspection Report
Monitoring
Deficiencies: 6
Dec 8, 2022
Visit Reason
The inspection was a mandated monitoring inspection conducted as a probation inspection per a special order issued on 06/17/2022 and a denial inspection per a notice of intent issued on 09/10/2022.
Findings
The inspection found multiple violations including failure to provide complete disclosure statements to residents, failure to address identified needs in individualized service plans, improper medication self-administration documentation, failure to provide treatments as ordered by physicians, unsafe smoking practices by a resident, and unsecured storage of cleaning supplies and hazardous materials.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure that the disclosure statement provided to resident contained all required information. |
| Facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). |
| Facility failed to ensure that for a resident with medications in their room the uniform assessment instrument (UAI) indicated the resident is capable of self-administering medication. |
| Facility failed to ensure treatments ordered by a physician or other prescriber were provided according to his instructions and documented. |
| Facility failed to ensure smoking by a resident is only done in areas designated by the facility and approved by the State Fire Marshall or local fire official. |
| Facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. |
Report Facts
Residents with disclosure statement issues: 3
Files to be audited monthly: 5
Completion dates for corrective actions: Dec 9, 2022
Completion dates for corrective actions: Jan 15, 2023
Resident admission date: Nov 27, 2022
Inspection Report
Complaint Investigation
Deficiencies: 5
Dec 8, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-12-05 regarding allegations in personnel, staffing and supervision, admission, retention and discharge of residents, resident care and related services, and buildings and grounds.
Findings
The investigation supported some, but not all, of the allegations with areas of non-compliance found in resident care and related services, personnel, and buildings and grounds. Multiple deficiencies were identified including failure to maintain staff records, inadequate personal care for residents, unlicensed medication administration, and poor building cleanliness and ventilation.
Complaint Details
The complaint was substantiated in part with findings of non-compliance in resident care and related services, personnel, and buildings and grounds. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure a record was established for a staff person. |
| Facility failed to ensure residents received personal assistance with bathing at least twice a week as required. |
| Facility failed to ensure staff responsible for medication administration were licensed by the Commonwealth of Virginia. |
| Facility failed to ensure the interior of the buildings were kept clean and free of rubbish. |
| Facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. |
Report Facts
Number of showers received by resident 2: 4
Number of showers received by resident 3: 3
Medication administration dates by unlicensed staff: 3
Inspection times: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Physical Plant Staff | Observed performing maintenance duties without a proper staff record; hired as a contractor without documentation. |
| Staff 2 | Interviewed and stated that Staff 1 was hired as a contractor on a 90-day trial basis without documentation. | |
| Staff 4 | Administered medications without proper licensure; removed from schedule pending testing; called Board of Nursing during inspection. |
Inspection Report
Monitoring
Deficiencies: 12
Oct 20, 2022
Visit Reason
A non-mandated monitoring inspection was conducted as a follow-up for a previous inspection that required an intensive plan of correction issued on 08/26/2022, a probation inspection indicated in a special order issued on 06/17/2022, and a denial inspection indicated in a notice of intent issued on 09/10/2022.
Findings
The inspection found multiple violations including failure to perform required six-month reviews for residents in the special care unit, acting administrator exceeding 90 days, incomplete sex offender registry checks prior to admission, improper medication management and documentation, unsecured hazardous materials, unclean and stained facility areas, foul odors, insect infestations, and failure to post required notices on the premises.
Deficiencies (12)
| Description |
|---|
| Failed to ensure six-month review for appropriateness of resident's continued residence in special care unit. |
| Facility failed to ensure acting administrator was not in position for more than 90 days. |
| Failed to ascertain prior to admission whether a potential resident was a registered sex offender. |
| Failed to ensure residents with medications in their rooms had uniform assessment instrument indicating capability of self-administration. |
| Failed to ensure medications remained in pharmacy issued container with proper labeling until administered. |
| Failed to ensure medications were administered according to physician's instructions and standards of practice. |
| Failed to ensure all required documentation was on the medication administration record. |
| Failed to ensure cleaning supplies and hazardous materials were stored in a locked area. |
| Failed to ensure interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish. |
| Failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. |
| Failed to ensure buildings were kept free of infestations of insects. |
| Failed to have posted on the premises the notice of the commissioner's intent to revoke or deny renewal of the facility's license. |
Report Facts
Days acting administrator exceeded: 107
Number of physician orders for Zyrtec: 3
Number of medication administration records (MARs) reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Inspector of record conducting the monitoring inspection. |
| Staff 1 | Acting Administrator | Named in deficiency for exceeding 90 days as acting administrator. |
| Staff 2 | Facility administrator of record as of 10/17/2022 and involved in confirming acting administrator duration. | |
| Staff 3 | Involved in medication administration findings and interviews. | |
| Staff 5 | Observed cleaning floors and interviewed regarding stain removal. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 4, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/04/2022 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related inspection; the complaint was not substantiated as evidence did not support the allegation of non-compliance.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 9, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 09/09/2022 regarding allegations in the areas of administration and administrative services and buildings and grounds.
Findings
The inspection found violations related to unauthorized residency of staff and poor maintenance and cleanliness issues in the facility, including stained ceilings, wet and stained bathroom floors, food debris, and unsanitary conditions in resident rooms. Plans of correction were provided to address these issues.
Complaint Details
Complaint related: Yes. The complaint was substantiated with violations issued based on evidence gathered during the inspection.
Deficiencies (2)
| Description |
|---|
| Licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department, including unauthorized residency of staff and spouse in a resident room. |
| Facility failed to ensure the interior of the building was maintained in good repair and kept clean, including stained ceiling, wet and stained bathroom floor, food crumbs and utensils on floor, and unsanitary items attracting gnats in resident rooms. |
Report Facts
Inspection duration: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Named in finding regarding unauthorized residency in facility room E29 | |
| Staff 2 | Provided confirmation and observations related to violations in room E29 and resident rooms |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 2, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-08-18 regarding allegations in the areas of admission, retention and discharge of residents and resident care and related services.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified, including failure to secure medication storage and failure to keep medications in pharmacy-issued containers until administration.
Complaint Details
Complaint was received regarding admission, retention and discharge of residents and resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that medication storage containers were locked when medications and dietary supplements were administered. |
| Facility failed to ensure medications remained in the pharmacy issued container with prescription label attached until administered to a resident. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Inspector conducting the complaint investigation. |
| Staff 1 | Identified as the staff who left the medication cart unlocked and unattended; received verbal warning and education. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 26, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-07-19 regarding allegations in staffing and supervision, resident care and related services, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation found multiple violations related to staffing shortages, including failure to ensure at least two direct care staff members were awake and on duty at all times in both the assisted living and special care units. Additional findings included inadequate administration oversight and incomplete documentation on resident medication administration records.
Complaint Details
The complaint was substantiated with evidence supporting non-compliance in staffing and supervision, resident care, and additional requirements for adults with serious cognitive impairments. Violations were issued accordingly.
Deficiencies (5)
| Description |
|---|
| Failed to ensure at least two direct care staff members awake and on duty at all times in the assisted living building. |
| Failed to ensure at least two direct care staff members awake and on duty at all times in the special care unit when 20 or fewer residents are present. |
| Failed to ensure at least two direct care staff members awake and on duty at all times in the special care unit when 22 or fewer residents are present. |
| Administrator failed to be responsible for general administration, management, and oversight of day-to-day operations including implementing all required policies, procedures, and services. |
| Failed to ensure all required information was documented on resident medication administration records (MARs). |
Report Facts
Inspection dates: Inspection conducted on 07/26/2022 and 08/02/2022
Residents in special care unit: 16
Staff shifts: Staff 2 scheduled 7:00PM to 7:00AM; Staff 9 clocked in at 11:45AM and was only direct care staff from 12:30PM to 4:00PM on 07/23/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 6
Jul 15, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 07/11/2022 regarding allegations in the area of resident care and related services at Carriage Hill Retirement.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in resident care and related services, including failures in completing the uniform assessment instrument, providing adequate personal assistance with bathing, medication administration errors, and issues with cleanliness and odor in resident rooms.
Complaint Details
The complaint investigation was substantiated in part; some allegations were supported by evidence, specifically regarding resident care and related services.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure that the uniform assessment instrument (UAI) was completed as required. |
| Facility failed to ensure that personal assistance and care were provided to each resident as necessary, including assistance with bathing at least twice a week. |
| Facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions. |
| Facility failed to ensure that bed linens were changed as needed. |
| Facility failed to ensure that all buildings were free from foul and stale odors. |
| Facility failed to ensure that all furnishings, including furniture and toilets, were kept clean. |
Report Facts
Inspection duration: 2
Inspection duration: 1.5
Plan of correction submission timeframe: 5
Plan of correction submission timeframe: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint investigation |
| Dr. Bell | Notified of errors with insulin administration and documentation of meal consumption | |
| Staff 3 | Named in medication administration violation and received written counseling | |
| Staff 4 | Involved in medication administration and shower documentation issues | |
| Staff 5 | Interviewed regarding resident bathing assistance | |
| Staff 7 | Terminated due to failure to maintain cleanliness standards |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 24, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 06/22/2022 regarding allegations in the area(s) of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related inspection; allegations in resident care and related services were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 5
Jun 24, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 06/23/2022 regarding allegations in the areas of staffing/personnel and resident care and related services.
Findings
The investigation supported the allegations of non-compliance with standards and laws, resulting in violations issued. Deficiencies included failure to ensure direct care staff met training requirements, failure to implement the medication management plan, failure to administer medications according to physician instructions, failure to provide ordered medical treatments, and failure to properly document medication administration records.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance related to staffing/personnel and resident care.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that staff providing direct care met required training. |
| Facility failed to implement their medication management plan. |
| Facility failed to ensure all medications were administered in accordance with physician's instructions. |
| Facility failed to ensure medical procedures or treatments ordered by a physician were provided and documented. |
| Facility failed to ensure all required information was documented on resident medication administration records (MARs). |
Report Facts
Inspection duration: 7
Physician order date: May 9, 2022
Physician order date: Jun 23, 2022
Medication dosage: 30
Medication administration missed: 3
Inspection Report
Renewal
Census: 61
Deficiencies: 11
Jun 13, 2022
Visit Reason
The inspection was a renewal inspection conducted on June 13, 2022, to assess compliance with applicable standards and laws for the assisted living facility license renewal.
Findings
The inspection identified multiple areas of non-compliance including infection control, administration oversight, medication management, physical plant maintenance, and resident care documentation. Violations were documented and plans of correction were requested to address these deficiencies.
Deficiencies (11)
| Description |
|---|
| Failure to ensure infection control policies consistent with CDC recommendations were followed during medication cart audit. |
| Administrator failed to be responsible for general administration, management, and oversight of day-to-day operations including policy implementation. |
| Failure to ensure annual fall risk rating was completed for residents assessed at assisted living level of care. |
| Failure to retain a discharge statement in resident records. |
| Failure to ensure medications were administered according to physician's instructions and medication aide standards. |
| Failure to ensure PRN medications ordered were available at the facility. |
| Failure to ensure cleaning supplies and hazardous materials were stored in a locked area. |
| Failure to maintain the interior of the building in good repair and keep it clean and free of rubbish. |
| Failure to ensure the building was free from foul and stale odors. |
| Failure to keep all furnishings, fixtures, and equipment clean and in good repair. |
| Failure to ensure temperatures in all resident areas did not exceed 80 degrees Fahrenheit. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Violations cited in prior renewal study: 31
Temperature readings: 81.5
Temperature readings: 82
Temperature readings: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the renewal inspection |
| Staff 3 | Registered medication aide involved in medication administration violation | |
| Staff 4 | Staff who observed glucometer storage and medication cart audit | |
| Staff 8 | Staff interviewed regarding discharge statement and medication administration | |
| Staff 10 | Staff interviewed regarding discharge statement |
Inspection Report
Renewal
Census: 60
Deficiencies: 4
Apr 28, 2022
Visit Reason
An unannounced, non-mandated inspection was conducted as the first of two inspections for the facility's Provisional license, reviewing high risk violations cited at the previous renewal inspection and during the licensure year.
Findings
The inspection identified multiple deficiencies including incomplete physical examination reports, missing resident personal and social information, failure to implement the medication management plan properly, and improper medication storage in the memory care building.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure physical examination reports for residents contained all required components. |
| Facility failed to ensure resident personal and social information contained all required components. |
| Facility failed to implement their medication management plan, including missing signatures on narcotic count logs. |
| Facility failed to ensure medications remained in the pharmacy issued container with prescription or direction label attached until administered. |
Report Facts
Residents in care: 60
Inspection duration hours: 5.5
Number of medication carts audited: 4
Number of staff trainings reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the inspection |
| Administrator | Participated in preliminary and final exit interviews | |
| Director of Nursing | Participated in preliminary exit interview and involved in medication management plan oversight | |
| Regional Director | Participated in preliminary exit interview | |
| Staff 1 | Observed with medication pills in resident's room during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 28, 2022
Visit Reason
An unannounced complaint inspection was conducted in response to a complaint received on 04/28/2022 regarding allegations about resident care, prohibited conditions, resident funds, staff hiring with criminal records, and activity provision at the facility.
Findings
The investigation did not support the complaint allegations, determining the complaint as not valid; however, violations were cited related to documentation of fall analyses, sex offender screening prior to admission, physician order signatures within 14 days, and valid oxygen source orders.
Complaint Details
Complaint was related to allegations about resident needing higher level of care, prohibited conditions, resident funds not received, staff hiring with criminal record, and lack of activities. The complaint was determined to be not valid based on investigation findings.
Deficiencies (4)
| Description |
|---|
| Facility failed to show documentation of an analysis of the circumstances of a fall and interventions initiated to prevent or reduce risk of subsequent falls after a resident fall. |
| Facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. |
| Facility failed to ensure physician's or other prescriber's orders were reviewed and signed by a physician or other prescriber within 14 days. |
| Facility failed to have a valid physician's or other prescriber's order that includes the oxygen source such as compressed gas or concentrators. |
Report Facts
Dates of resident falls: Falls occurred on 2022-02-06 and 2022-03-23
Resident admission date: Resident 1 admitted on 2021-08-19
Physician order date: Physician order dated 2022-03-29
Physician order date: Physician order dated 2022-01-23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint inspection |
| Director of Nursing | Participated in exit interview and mentioned in plan of correction | |
| Administrator | Participated in exit interview and mentioned in plan of correction | |
| Regional Director | Participated in exit interview | |
| Staff 2 | Completed Falls Risk Rating documents and noted missing physician signature | |
| Regional Marketing Director | Reviewed admission documentation and compliance | |
| Regional Marketing Representative | Working with Admissions team to ensure compliance |
Inspection Report
Monitoring
Deficiencies: 0
Apr 28, 2022
Visit Reason
The inspection was a monitoring visit including a joint investigation with local adult protective services following a self-reported incident received on 2022-04-22 regarding allegations in resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 18, 2022
Visit Reason
The licensing inspector conducted an unannounced complaint inspection in response to a complaint received on 03/18/2022 regarding allegations of an inappropriate discharge notice and a staff member in charge not being trained on their duties.
Findings
The investigation supported the allegations, determining the complaint valid. Multiple violations were cited including failure to train staff placed in charge, failure to notify residents of discharge reasons, failure to maintain confidentiality of records, failure to secure medication storage, and failure to ensure medications remained in pharmacy containers until administered.
Complaint Details
The complaint was substantiated based on the preponderance of evidence supporting allegations of inappropriate discharge notice and untrained staff member in charge.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that the staff member, prior to being placed in charge, was informed of and received training on duties and responsibilities with written documentation. |
| Facility failed to ensure that as soon as discharge planning begins, the resident was notified of the reason for the discharge. |
| Facility failed to ensure all records were treated confidentially and information was made available only when needed for care. |
| Facility failed to ensure that the medicine container used for storage of medications and dietary supplements prescribed for residents was locked. |
| Facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label attached, until administered to residents. |
Report Facts
Discharge notice days: 30
Inspection time: 1300
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 28, 2022
Visit Reason
The licensing inspector conducted an unannounced complaint inspection in response to a complaint received on 02/28/2022 regarding allegations that a resident's diet was not served correctly, medication was not received, and the cleanliness of the resident's room.
Findings
The investigation supported one of the allegations. The facility failed to ensure medications administered had a valid physician order and failed to keep furnishings, fixtures, and equipment, including showers, clean.
Complaint Details
The complaint investigation was substantiated for one allegation related to medication administration without a valid order and cleanliness issues in the resident's room.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that medications started by the facility had a valid order from a physician or other prescriber, including prescription, over-the-counter, and sample medications. |
| Facility failed to ensure all furnishings, fixtures, and equipment, including showers, were kept clean. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 02/28/2022 regarding resident to resident altercations and concerns about appropriate care and safety of residents.
Findings
The investigation found one allegation to be valid: the facility admitted a resident to the safe, secure unit without a primary psychiatric diagnosis of dementia, which is required by regulation. The facility updated its admission requirements accordingly.
Complaint Details
The complaint investigation was substantiated with one valid allegation related to inappropriate admission to the secured unit without a dementia diagnosis.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that a resident had a serious cognitive impairment due to a primary psychiatric diagnosis of dementia prior to being admitted to the safe, secure environment. |
Report Facts
Inspection Date: Feb 28, 2022
Resident Admission Date: Jan 28, 2022
Resident Physical Examination Date: Dec 27, 2021
Assessment Date: Jan 26, 2022
Exit Interview Date: Mar 9, 2022
Return Notice Deadline: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 31, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation in response to a complaint received on 01/31/2022 regarding infection control procedures and housekeeping staff administering Covid-19 tests to residents.
Findings
After reviewing documentation, touring the facility, and conducting staff interviews, the department found no violations related to the complaint and determined the complaint was not valid.
Complaint Details
The complaint was investigated and found to be not valid based on the department's review completed on 06/15/2022.
Inspection Report
Complaint Investigation
Deficiencies: 14
Jan 31, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 01/31/2022, with additional on-site inspections on 02/09/2022 and 03/18/2022 involving local adult protective services and the long-term care ombudsman. The investigation addressed allegations including confidentiality breaches, multiple resident deaths, resident care issues, lack of direct care staff, a resident overdose, special diet concerns, housekeeping deficiencies, and untrained staff providing care during 12/24-25/2021.
Findings
The investigation substantiated four of the allegations and identified additional violations unrelated to the complaint. Deficiencies included insufficient direct care staff on duty, failure to report major incidents timely, incomplete individualized service plans, unsecured resident records, failure to post menus conspicuously, medication administration errors including unlicensed staff and improper medication supervision, inadequate signage for oxygen use, poor housekeeping and cleanliness, unsecured hazardous materials, and incomplete documentation of resident rounds.
Complaint Details
The complaint investigation was substantiated for four allegations including confidentiality breaches, lack of direct care staff, resident overdose, and housekeeping deficiencies. Additional violations unrelated to the complaint were also cited.
Deficiencies (14)
| Description |
|---|
| Failed to ensure at least two direct care staff members awake and on duty at all times in each building responsible for resident care and supervision. |
| Failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened resident safety. |
| Failed to ensure individualized service plans included all required components. |
| Failed to keep all resident records in a locked area. |
| Failed to ensure the current week's menu was posted in an area conspicuous to residents. |
| Failed to ensure the primary physician was aware of new medication orders and treatments after resident hospitalization. |
| Failed to ensure staff administering medications were authorized by the Virginia Control Act. |
| Failed to ensure medications were administered according to physician's instructions and medication aide standards. |
| Failed to post 'No Smoking-Oxygen in Use' signs when oxygen therapy was provided. |
| Failed to ensure bed linens were changed at least every seven days and more often if needed. |
| Failed to ensure cleaning supplies and hazardous materials were stored in a locked area. |
| Failed to keep the interior of the building clean. |
| Failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. |
| Failed to document rounds for residents unable to use signaling devices including date, time, and staff signature. |
Report Facts
Inspection dates: 3
Timeframe of staffing deficiency: 8
Medication administration dates: 9
Bed linen change frequency: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Conducted the complaint investigation and inspections |
| Staff 2 | Interviewed regarding staffing and medication administration | |
| Staff 3 | Licensed Registered Medication Aide | Administered medications with expired license |
| Staff 5 | Administered medications with expired license | |
| Staff 6 | Worked night shift but not trained as direct care staff | |
| Staff 7 | Worked night shift but not trained as direct care staff | |
| Staff 8 | Only direct care staff member on duty during night shift on 12/24-25/2021 | |
| Staff 10 | Reported medication hoarding issue |
Inspection Report
Monitoring
Deficiencies: 3
Jan 31, 2022
Visit Reason
The inspection was an unannounced focused monitoring inspection initiated via phone on 2021-12-13 and an on-site inspection on 2022-01-31 to follow up on a facility reported incident of an elopement of a resident from the facility's safe, secure unit that occurred on 2021-12-06.
Findings
The facility was found to have failed to ensure residents' individualized service plans included all required components, failed to ensure supervision of resident schedules and activities including wandering from the premises, and failed to ensure licensed health care professionals administered PRN medications with appropriate orders. The resident involved in the elopement was found unharmed and no hospitalization was required.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure residents’ individualized service plans included all required components. |
| Facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
| Facility failed to ensure licensed health care professionals administered PRN medications and that medication orders included symptoms indicating use and directions if symptoms persist. |
Report Facts
Inspection dates: 2
Distance resident eloped: 4.2
Temperature range: 50
Temperature range: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 12, 2022
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2022-01-09 regarding allegations in the area of resident care and related services at Carriage Hill Retirement.
Findings
The investigation supported some, but not all, of the allegations. Violations were found related to failure to meet health care service needs of a resident, failure to obtain valid physician orders prior to discontinuing medications or treatments, and failure to ensure physician's oral orders were reviewed and signed within 14 days.
Complaint Details
The complaint was substantiated in part; evidence supported some of the allegations related to resident care and related services. A violation notice was issued.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that the health care service needs of a resident were met, including inadequate wound care and lack of documentation of ongoing wound cleaning and dressings. |
| Facility failed to obtain a valid order from a physician or other prescriber prior to discontinuing a medication, dietary supplement, diet, medical procedure, or treatment. |
| Facility failed to ensure a physician's or other prescriber's oral order was reviewed and signed by a physician or other prescriber within 14 days. |
Report Facts
Inspection dates: 2
Resident admission date: Jul 15, 2021
Medication administration record periods: 4
Physician order date: Aug 31, 2021
Inspection Report
Renewal
Census: 63
Deficiencies: 31
Nov 30, 2021
Visit Reason
An unannounced renewal study was conducted on 11/30/2021 to assess compliance with the Standards for Assisted Living Facilities, including a tour, medication observation, record reviews, and staff interviews.
Findings
The inspection identified multiple deficiencies including failures in infection control, incident reporting, staff training, medication management, resident care documentation, physical plant maintenance, and staff record compliance. Plans of correction were provided for most violations.
Deficiencies (31)
| Description |
|---|
| Facility failed to ensure infection control policies consistent with CDC recommendations were followed regarding labeling of glucometers. |
| Facility failed to report a major incident threatening resident safety to the regional office within 24 hours. |
| Facility failed to ensure staff received at least 2 hours of annual infection control training. |
| Facility failed to ensure annual tuberculosis risk assessments were submitted for staff. |
| Facility failed to ensure staff training on restraints for residents who may be restrained. |
| Facility failed to ensure staff training on managing residents with agitated behaviors by qualified health professionals. |
| Facility failed to ensure direct care staff training for residents with aggressive behaviors occurred at least annually. |
| Facility failed to ensure physical examination reports contained descriptions of allergic reactions. |
| Facility failed to obtain all required personal and social information at admission. |
| Facility failed to ensure uniform assessment instrument (UAI) was completed and signed as required. |
| Facility failed to ensure comprehensive individualized service plans (ISP) were accurate and consistent with assessments. |
| Facility failed to note substitutions on the written schedule of activities. |
| Facility failed to review resident rights annually with residents and staff and document the review. |
| Facility failed to ensure confidential treatment of records; narcotic medication administration records were left unattended. |
| Facility failed to ensure menus for meals were dated and posted conspicuously. |
| Facility failed to meet minimum daily dietary requirements based on USDA guidance. |
| Facility failed to have a current dietary manual readily available to food preparation personnel. |
| Facility failed to implement medication management plan, including medication availability, documentation, and narcotic counts. |
| Facility failed to ensure no medication was changed without a valid physician order. |
| Facility failed to ensure physician orders were reviewed and signed within 14 days. |
| Facility failed to ensure required medications were refrigerated properly. |
| Facility failed to ensure residents self-administering medications kept them in an out-of-sight place. |
| Facility failed to ensure medications remained in pharmacy-issued containers until administered. |
| Facility failed to ensure PRN medications were available as ordered. |
| Facility failed to ensure restraints were imposed only with a physician's written order specifying conditions and duration. |
| Facility failed to ensure all required furnishings were present in resident rooms. |
| Facility failed to ensure hazardous materials were stored in a locked area. |
| Facility failed to ensure buildings were well-ventilated and free from foul odors. |
| Facility failed to ensure fixtures were kept clean and in good repair. |
| Facility failed to ensure sworn statements or affirmations were completed for all applicants for employment. |
| Facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment. |
Report Facts
Residents in care: 63
Staff infection control training hours: 1.5
Medication administration omissions: 11
Medication administration omissions: 8
Medication administration omissions: 2
Medication cart narcotic count missing signatures: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the renewal inspection |
| Staff 2 | Mentioned in relation to medication availability and narcotic count signature | |
| Staff 3 | Mentioned in relation to infection control training and tuberculosis screening | |
| Staff 4 | Mentioned in relation to tuberculosis screening and medication storage | |
| Staff 5 | Mentioned in relation to aggressive behavior training and medication storage | |
| Staff 6 | Mentioned in relation to resident care and activity scheduling | |
| Staff 7 | Mentioned in relation to staff record review | |
| Staff 8 | Mentioned in relation to sworn statement completion and criminal background check | |
| Staff 9 | Mentioned in relation to criminal background check | |
| Staff 10 | Mentioned in relation to criminal background check | |
| Staff 11 | Mentioned in relation to medication storage | |
| Administrator | Facility Administrator involved in inspection exit interviews and corrective actions | |
| Regional Director of Operations | Participated in post-inspection conference | |
| New DON | Director of Nursing | Hired to oversee medication management and staff training |
| Business Office Manager | Hired to oversee staff training logs | |
| Kitchen Manager | Responsible for menu compliance and dietary manual availability |
Inspection Report
Monitoring
Deficiencies: 1
Oct 12, 2021
Visit Reason
A non-mandated monitoring inspection regarding an intensive plan of correction (IPOC) was initiated on 10/12/2021 and concluded on 10/13/2021 to verify compliance with the plan of correction.
Findings
No repeat violations were found related to the IPOC; however, a violation was identified regarding failure to implement the medication management plan to ensure accurate counts of controlled substances.
Deficiencies (1)
| Description |
|---|
| Facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances, evidenced by discrepancy in morphine counts. |
Report Facts
Controlled substance discrepancy: 2.75
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 10/12/2021 regarding allegations of resident care, related services, and buildings and grounds at Carriage Hill Retirement.
Findings
The investigation found one valid allegation related to buildings and grounds and other violations related to failure to ensure residents received appropriate health care services and failure to maintain cleanliness of the interior of all buildings.
Complaint Details
The complaint investigation was substantiated in part, with one valid allegation regarding buildings and grounds. Other violations were cited related to resident care and cleanliness.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that the health care service needs of residents were met by assisting residents in making appropriate arrangements for health care services, evidenced by missed podiatry appointments due to transportation issues. |
| Facility failed to ensure that the interior of all buildings were kept clean, evidenced by strong urine odor and sticky floor in a resident's room and marks on the wall beside the resident's bed. |
Report Facts
Inspection dates: Inspection conducted on October 12, 2021 and November 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Conducted the complaint inspection |
Inspection Report
Deficiencies: 1
Aug 4, 2021
Visit Reason
A non-mandated self-report inspection was initiated following a self-report received by the department regarding allegations related to staff and resident care and medication management. The Administrator was contacted to conduct the investigation.
Findings
The investigation supported the self-report of one standard of non-compliance related to medication administration documentation. Violations were issued for failure to document all medications administered to residents on the medication administration record (MAR).
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that at the time a medication is administered, all medications administered to residents were documented on the medication administration record (MAR). |
Report Facts
Medication quantity received: 30
Medication quantity received: 60
Medication quantity received: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Conducted the investigation and inspection |
| Staff 1 | Nurse who signed for receiving medications and administered medications without proper documentation | |
| Staff 2 | Provided medication card picture evidence to the licensing inspector | |
| Staff 4 | Confirmed medication receipt for resident 3 |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 6, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding infection control, resident care and related services, staffing and supervision, and the criminal history record report. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. However, two non-complaint related violations were identified: the infection control program lacked required components, and the facility failed to ensure accurate counts of controlled substances during medication administration staff changes.
Complaint Details
The complaint investigation was initiated on 2021-05-06 and concluded on 2021-05-12. The complaint involved allegations in infection control, resident care, staffing and supervision, and criminal history record report. The investigation found no substantiated violations related to the complaint.
Deficiencies (2)
| Description |
|---|
| The infection control program did not include sanitation of rooms, cleaning and disinfecting procedures, agents and schedules, and adherence to Virginia Department of Health recommendations. |
| The facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, as evidenced by missing signatures on the Shift to Shift Narcotic Count Sign off Sheet. |
Report Facts
Dates with missing medication log signatures: 5
Inspection Report
Monitoring
Deficiencies: 1
Mar 25, 2021
Visit Reason
A monitoring inspection was initiated due to a self-reported incident regarding allegations in the areas of resident care and related services. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation did not support the self-report of non-compliance with standards or law. However, a violation was identified related to the failure to ensure individualized service plans were reviewed at least once every 12 months.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that individualized service plans (ISP) were reviewed at least once every 12 months. |
Inspection Report
Complaint Investigation
Deficiencies: 11
Mar 25, 2021
Visit Reason
A complaint inspection was initiated on 03/25/2021 due to allegations regarding personnel, admission, retention and discharge of residents, resident care and related services at Carriage Hill Retirement.
Findings
The investigation supported one allegation of non-compliance with standards or law, resulting in violations issued. Deficiencies included failure to maintain a written work schedule indicating staff in charge, incomplete uniform assessment instruments, inadequate individualized service plans, failure to ensure residents were dressed in clean clothing, failure to provide clean clothing and linens for incontinent residents, failure to record rehabilitative service progress, failure to notify physicians of significant weight loss, failure to document medication discontinuation orders, and failure to maintain building cleanliness and repair.
Complaint Details
The complaint inspection was initiated due to allegations in personnel, admission, retention and discharge of residents, resident care and related services. The investigation supported one allegation of non-compliance and violations were issued. Staff member was terminated related to failure to change resident's clothes and linens when soiled.
Deficiencies (11)
| Description |
|---|
| Facility failed to maintain a written work schedule indicating staff in charge during each shift. |
| Facility failed to ensure the uniform assessment instrument was completed as required. |
| Facility failed to ensure individualized service plans included all required components. |
| Facility failed to ensure all residents are dressed in clean clothing. |
| Facility failed to ensure incontinent residents have clean clothing and linens each time they are soiled or wet. |
| Facility failed to record evaluations of progress and other pertinent rehabilitative service information in resident records. |
| Facility failed to notify resident's attending physician of significant weight loss of 5% in one month. |
| Facility failed to ensure no medication or treatment was discontinued without a valid physician order. |
| Facility failed to maintain the interior of buildings in good repair and cleanliness. |
| Facility failed to ensure furnishings were kept clean and in good repair and condition. |
| Facility failed to document rounds for residents unable to use signaling devices, including name, date, time, and staff member. |
Report Facts
Weight loss percentage: 5
Dates of inspection: Inspection initiated on 2021-03-25 and concluded on 2021-05-13.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Conducted the inspection and investigation. |
| Staff 1 | Interviewed multiple times regarding deficiencies and evidence. | |
| Staff 2 | Terminated for failure to change resident's clothes and linens when soiled. | |
| Director of Nursing | Director of Nursing | Responsible for oversight of resident weights, medication orders, and ensuring rounds documentation. |
| Care Plan Coordinator | Responsible for ensuring initial UAI/ISP needs align and are documented. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Mar 15, 2021
Visit Reason
A virtual complaint inspection was initiated on 03/15/2021 due to a complaint received regarding allegations in the areas of personnel, resident care and related services, buildings and grounds, and emergency preparedness. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation supported four allegations of non-compliance with standards or law, resulting in violations issued. Key findings included staff providing services beyond their scope of practice, failure to update individualized service plans with resident condition changes, inadequate personal care assistance documentation, medication administration errors, and incomplete medication orders.
Complaint Details
The complaint investigation was substantiated with four allegations of non-compliance supported by evidence in personnel practices, resident care, building and grounds, and emergency preparedness.
Deficiencies (7)
| Description |
|---|
| Direct care staff responsible for residents with special health care needs provided services beyond their scope of practice and training. |
| Individualized service plans (ISPs) were not reviewed and updated as resident conditions changed. |
| Residents did not consistently receive personal assistance and care with bathing at least twice a week as required. |
| Medication aides or licensed persons failed to routinely communicate medication administration issues or observations to prescribing physicians. |
| Physician or prescriber orders for medications and dietary supplements lacked diagnosis, conditions, or specific indications for administration. |
| Medications were not administered in accordance with physician or prescriber instructions, including incorrect insulin dosing. |
| Medication administration records (MARs) did not include initials of direct care staff administering medications. |
Report Facts
Medication administration errors: 7
Shower documentation gaps: 6
Medication refusals: Resident 2 refused multiple medications daily from January through mid-March 2021.
Inspection Report
Complaint Investigation
Deficiencies: 4
Mar 1, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding admission, retention, and discharge of residents at the facility. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, several violations unrelated to the complaint were identified, including failure to ensure physical examinations within 30 days preceding admission, failure to update fall risk ratings after falls, failure to update individualized service plans as resident conditions changed, and failure to ensure prompt staff response to resident needs.
Complaint Details
The complaint investigation was initiated on 03/01/2021 and concluded on 03/17/2021. The complaint concerned admission, retention, and discharge of residents. The evidence gathered did not support the allegation of non-compliance with standards or law.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that within 30 days preceding admission, all residents had a physical examination by an independent physician. |
| Facility failed to ensure that the fall risk rating was reviewed and updated after a fall for residents who meet the criteria for assisted living care. |
| Facility failed to ensure that individualized service plans (ISP) were reviewed and updated as the condition of a resident changes. |
| Facility failed to ensure prompt response by staff to resident needs as reasonable to the circumstances. |
Report Facts
Dates of resident record entries: Jul 30, 2020
Dates of fall risk rating: Jul 24, 2020
Dates of ISP and UAI assessments: Jul 29, 2020
Dates of psychiatric periodic evaluation: Jan 12, 2021
Medication administration record period: Feb 1, 2021
Medication administration record period: Feb 14, 2021
Date of resident agitation incident: Feb 11, 2021
Date resident returned from hospital: Feb 16, 2021
Date of APS involvement note: Feb 18, 2021
Date resident called 911: Feb 28, 2021
Date of resident reported threats: Mar 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Current inspector conducting the complaint investigation |
| Staff 1 | Interviewed staff confirming deficiencies and reporting resident behavior and ECO request | |
| Staff 3 | Staff who reached out to collateral contacts and adult protective services |
Inspection Report
Monitoring
Deficiencies: 1
Jan 19, 2021
Visit Reason
A monitoring inspection was initiated due to a self-reported incident regarding allegations in resident care and medication administration. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation supported the self-report of non-compliance with standards related to medication administration, specifically that medications were not kept in pharmacy-issued containers with labels until administered. Violations were issued based on these findings.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. |
Report Facts
Incident date: Jan 17, 2021
Staff involved: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Current inspector conducting the investigation |
| Director of Nursing | Providing on the job training and observing medication passes |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 29, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding resident care and related services and building and grounds conditions at the facility.
Findings
The investigation found non-compliance with standards, specifically that the facility failed to keep the interior of the building clean, including urine observed on the floor and dirty bathroom conditions in a resident's room.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation supporting the allegation of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to keep the interior of the building clean, including urine on the floor and dirty bathroom in resident's room. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Current Inspector conducting the complaint investigation. |
| Director of Nursing | Monitoring timeliness of patient care and checking resident rooms for infection control as part of plan of correction. | |
| Administrator | Overseeing housekeeping operations and spot checking rooms daily as part of plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 23, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding administration and administrative services related to infection control at the facility.
Findings
The investigation found that the facility failed to implement their infection control policy, including staff not wearing masks as required and lack of social distancing among residents. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated as the evidence supported non-compliance with infection control standards, including staff not wearing masks prior to a complaint and insufficient mask supply initially.
Deficiencies (1)
| Description |
|---|
| Facility failed to implement their infection control policy, including staff not wearing masks and residents not socially distanced. |
Report Facts
Residents observed at tables: 10
Residents observed at tables: 15
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 23, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding resident care and related services at the facility.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law.
Complaint Details
A complaint was received by the department regarding allegations in the areas of resident care and related services. The evidence gathered during the investigation did not support the allegations.
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