VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carrington Place at Wytheville-Birdmont Center
990 Holston Road
Wytheville, VA 24382
(276) 228-5595

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Dec. 19, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 General Provisions. 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Comments:

Two licensing inspectors conducted a one day unannounced mandated licensing renewal inspection at Carrington Place in Wytheville on 12/19/2019. The inspection began at 9:30 am and concluded at 3:03 pm. During this inspection required postings were checked, the noon medication pass was observed, medication cart audits were conducted, medication administration records were reviewed, lunch was observed, building was observed, resident and staff interactions were observed, and a sample of resident and staff files were reviewed. There were 79 residents in care at the time of the inspection. An exit meeting was conducted with the administrator and other key staff on 12/19/2019 and at that time opportunity was given to find items that were not available in files. As a result of this inspection 16 violations are being cited. Please develop a plan of correction for each of the cited violations along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days (01/09/2019 ) of receipt. If you have any questions or concerns please contact your licensing inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records and subsequent tuberculosis screening, the facility failed to ensure every staff member submitted an annual risk assessment. EVIDENCE: The following staff members did not have a current annual tuberculosis risk assessment: 1. The most recent tuberculosis assessment for staff # 2 was dated 11/02/2017. 2. The most recent tuberculosis assessment for staff #3 was dated 09/29/2016. 3. The most recent tuberculosis assessment for staff # 1 was dated 07/04/2017. 4. The most recent tuberculosis assessment for staff # 4 was dated 01/03/2018. 5. The most recent tuberculosis assessment for staff # 5 was dated 03/27/2017.
Plan of Correction:	Staff records and health requirements, staff # 1, 2, 3, 4, 5 tuberculosis assessment was completed on (01/03/2020) Quality review of tuberculosis of current staff completed by Administrator/Designee by (1/17/2020). Follow up based on findings. Retirement Center Director of Nursing Services RCDNS and Executive Director (ED) educated by the Regional Director of Clinical Operations (RDCO) that each person is required to be evaluated annually and submit the risks of a risk assessment, documenting the individual is free from tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Administrator/Designee will monitor monthly times 3 months and as indicated thereafter. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident records and physical examination reports, the facility failed to ensure all the required information was contained on the report for five residents in a sample of ten. EVIDENCE: 1. Resident #1 was admitted to the facility on 11/04/2019. The Physical Examination report for this resident dated 10/25/2019 lists Penicillin and Sulfa as allergies there was no description of reactions to these allergies listed on the exam. 2. Resident #2 was admitted to the facility on 09/01/2019. The Physical Examination report dated 08/28/2019 for this resident lists Alendronate, Penicillin?s, and Sulfonamides as allergies and there was no description of reactions to these allergies documented on the physical exam. 3. Resident #3 was admitted to the facility on 09/28/2019. This resident was accepted to the facility as an emergency placement. Her physical exam dated 10/02/2019 lists Dyazide and Indemythein as allergies and no description of reactions to these allergies were documented on the exam. 4. Resident #5 was admitted to the facility on 05/01/2019. The physical examination report for this resident dated 05/01/2019 did not specify whether or not she is capable of self-administering her medications. 5. Resident #6 was admitted to the facility on 11/5/2019. The physical exam for this resident dated 10/30/2019 listed she is allergic to Aspirin. No description of reactions to this allergy was documented on the exam.
Plan of Correction:	Resident #1 physical examination report updated with description of reactions to identified allergies. Resident #2 Physical examination report updated with description if reactions to identified allergies. Resident #3 Physical examination report updated with description of reactions to identified allergies. Resident #5 Physical examination report updated to specify resident capability of self-administration of own medications. Resident #6 physical examination report updated with description of reactions to identified allergies. Quality review of physical examination and reports for other residents for allergies with reactions and statement specifying whether the individual is or is not capable of self-administering medication completed by RCDNS/Designee by (01/17/2020). Follow up based on findings. RMA's educated by RCDNS/Designee, that within 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain, any known allergies and description of the person's reactions and a statement that specifies whether the individual is or is not capable of self-administering medication. RCDNS/Designee will montior prior to admission times 3 months and as indicated thereafter. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on review of resident records and Individualized Service Plans (ISPs), the facility failed to ensure all areas of identified needs were included on the ISPs for two residents in a sample of ten. EVIDENCE: 1. Resident #4 was admitted to the facility on 06/03/2014. This resident signed a durable and medical power of attorney on 09/09/2013. The ISP for this resident dated 07/02/2019 did not include the power of attorney as a need. 2. Resident #6 was admitted to the facility on 11/05/2019. This resident has a signed power of attorney dated 08/27/2004. This was not listed as a need for this resident on her ISP dated 12/04/2019.
Plan of Correction:	Resident #4 ISP has been updated on 01/03/2020 to reflect the need for a Power of Attorney. Resident #6 ISP has been updated on 01/03/2020 to reflect the need for a Power of Attorney. Quality review of ISP for other residents who have a Power of Attorney completed by RCDNS/Designee by (01/17/2020). Follow up based on findings. RCDNS & ED educated by the RDCO, that the comprehensive individualized service plan shall be completed within 30 days after admission and shall include the description of identified needs and date identified this includes the Power of Attorney if applicable. RCDNS/Designee will monitor on admission times 3 months and as indicated thereafter. [sic]
Standard #:	22VAC40-73-550-G
Description:	Based on review of staff records and annual resident rights review, the facility failed to ensure each staff member reviewed resident rights on an annual basis. EVIDENCE: The following staff members did not have an annual review of resident rights: 1. The most recent annual resident rights review for staff # 1 was dated 06/29/2017. 2. The most recent annual resident rights review for staff # 2 was dated 10/25/2017. 3. The most recent annual resident rights review for staff # 3 was dated 05/15/2018. 4. The most recent annual resident rights review for staff # 4 was dated 03/01/2018. 5. The most recent annual resident rights review for staff # 5 was dated 10/10/2017.
Plan of Correction:	Staff # 1, 2, 3, 4, 5 completed annual resident rights review by (01/13/2020). Quality review of annual resident rights review of other staff completed by the Administrator/Designee by (01/17/2020). Follow up based on findings. Staff educated by RCDNS/Designee, that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person. Evidence of this review shall be the acknowledgement of having been so informed, which shall include the date of the review and shall be filed in the staff person's record. Administrator/Designee will monitor monthly times 3 months and as indicated thereafter. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit, the facility failed to implement their medication management plan to ensure methods are put into place to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. Medication Cart #3 on the 3rd floor was found to have 13 unidentified pills laying loose in the bottom of the medication cart drawer. 2. The medication cart on the 1st floor was found to have two small loose pills found laying in the bottom of the medication cart drawers.
Plan of Correction:	The loose pills on Medication Cart #3/3rd floor were properly discarded on 12/19/2019. The loose pills on Medication Cart 1st floor were properly discarded on 12/19/2019.Quality review of facility medication carts completed by RCDNS/Designee by (01/17/2020). Follow up based on findings. RMA's educated by RCDNS/Designee, the methods to prevent the use of outdated, damaged, or contaminated medications to include properly discarding of any loose pills laying in the bottom of the medication carts. RCDNS/Designee will monitor weekly times 12 weeks and as indicated thereafter. Administration of medications and related provisions. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on observations made during the review of resident records, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinue by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1. Resident # 14 has a physician?s order to monitor blood pressure daily. There is no documentation to show this is being done and no one has signed off on the MAR to indicate this has been done. Staff # 1 could verified she could not locate the sheet where this information was recorded. 2. Resident # 14 has a physician?s order for Rulox Solution 10 ML by mouth three times daily between meals. This medication was not available on the medication cart. Staff # 1 could not locate this medication on the medication cart. There was no record of this medication being administered any during December 2019 and there was no discontinue order found in her file. 3. Resident # 12 is prescribed Docusate Sodium 100mg by mouth at bedtime. This was marked through on the MAR and says it is a duplicate order. There is not a duplication of this on the MAR for this resident. Staff # 5 verified by looking at the MAR for December 2019 that there was not a duplicate on the MAR. This medication was not available for Resident # 12 on the medication cart and has not been administered at all in December 2019. Staff # 1 verified this medication was not available on the medication cart. 4. Resident # 11 is prescribed PEG 3350 powder, dissolve 17gm in 6-8 ounces of beverage by mouth once daily. This medication was not available on the medication cart for this resident.
Plan of Correction:	Resident #14 Rulox (Maalox) solution was discontinued on 11/11/2019, medication administration record (MAR) clarified and updated for the month January 2020. Resident # 12 Colace medication order clarified on 01/01/2020 and medication is now available on medication cart. Resident #11 PEG 3350 (MiraLax) powder made available and placed on the medication cart on 12/19/2019. Quality review of physician orders for monitoring blood pressure, medication availability and available on medication cart for other residents completed by RCDNS/Designee by (01/17/2020.) Follow up based on findings. Registered Medication Aides (RMA's) educated by RCDNS/Designee, that no medication, dietary supplement, diet, medical procedure, or treatment shall be started. changed , or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over the counter, and sample medications. RCDNS/Designee will monitor weekly times 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the noon medication pass, the facility failed to administer medications and related provisions consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Staff # 5 did not put a protective barrier down when checking blood sugar of Resident #'s 11 &12 2. Staff #1 did not put a protective barrier down when checking blood sugar of Resident #'s 13, 14 & 15.
Plan of Correction:	Administration of medications and related provisions Staff #1 completed glucometer skills competency on (01/03/2020). Staff #5 completed glucometer skills competency on (01/06/2020). Quality review of glucometer skills competency for other RMA's completed by RCDNS/Designee by (01/17/2020). Follow up based in findings. RMA's educated by RCDNS/Designee, that medications shall be administered in accordance with the physician's or other prescribers instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. RCDNS/Designee will monitor weekly times 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-680-I
Description:	Based on observations made during the review of the Medication Administration Record (MAR), the facility failed to ensure the symptoms for which medication was given and the effectiveness was recorded on the back of the MAR. EVIDENCE: 1. Resident #15 is prescribed Oxycodone 5 mg tablets, one tablet by mouth twice daily as needed. The prn medication was administered on December 1-18 2019. The effectiveness was not recorded on December 1, 4, 10, 11, 13, and 14.
Plan of Correction:	Resident #15 was assessed and pain evaluation completed by a licensed nurse on (01/03/2020). Quality review of documented effectiveness of PRN medications for other residents receiving PRN pain medication completd by RCDNS/Designee by (01/17/2020). Follow up based on findings. RMA's educated by RCDNS/Designee, that the MAR shall include for "as needed" (PRN) medications, symptoms for which medication was given, exact dosage given and effectiveness. RCDNS/Designee will monitor weekly times 12 weeks, and as indicated therafter. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the medication cart audit and review of the Medication Administration Record (MAR) and the physician?s orders, the facility failed to have medications ordered for PRN (as needed) administration available for the specific resident. EVIDENCE: 1. Resident # 15 is prescribed Proventil AER HFA 1-2 puffs by mouth every four hours as needed for COPD. This medication was not available for this resident on the medication cart. Staff # 1 verified she could not locate this medication on the cart.
Plan of Correction:	Administration of medications and related provisions Resident #15 received Proventil AER HFA on (12/19/2019). Quality review of medication availability and available on medication cart for other residents complete by RCDNS/Designee by (01/17/2020). Follow up based on findings. RMA's educated by RCDNS/Deignee, that medications ordered for PRN administration shall be available, properly labeled for the specific residence, and properly stored at the facility. RCDNS/Designee will monitor weekly times 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-700-1
Description:	Based on review of the Medication Administration Records (MARs) and physician?s orders, the facility failed to have a valid order that included the source which the oxygen should come from. EVIDENCE: 1. Resident #15 has an order for Oxygen via nasal cannula 2 liters continuous. The order does not state the source which the oxygen should be received from such as compressed gas or concentrator.
Plan of Correction:	Resident #15 oxygen therapy order was clarified on (01/03/2020) to include the oxygen source. Quality review of oxygen therapy orders to include oxygen source for other residents receiving oxygen completed by RCDNS/Designee by (01/17/2020). Follow up based on findings. RMA's educated by RCDNS/Designee, the facility shall have a valid physician's or other prescriber's order that includes the following: the oxygen source, such as compressed gas or concentrators, the delivery device, such as nasal cannula, reservoir cannulas or masks and the flow rate deemed therapeutic for the resident. RCDNS/Designee will monitor weekly times 12 weeks and indicated thereafter. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to maintain the interior and exterior of the building in good repair and keep it clean. EVIDENCE: 1. The front lobby entrance has a coffee bar. The table runner which used to be white in color is now stained with black and brown circles which appears to be spilled coffee. There are also particles of sugar and creamer scattered about. 2. The activities room located downstairs had left over popped popcorn in the floor. According to Staff # 6 the popcorn was served the previous day at 4pm. 3. The day room area on the 3rd floor had trash and crumbs in the floor. There was a tray with a bowl and a cup, a fork and a spoon and a coffee cup. The bowl was full of water and had a dead bug in it.
Plan of Correction:	The table runner was removed on (12/19/2019). The front lobby was cleaned on (12/20/2019). The popcorn on the floor in the activity room was cleaned up on (12/20/2019). The day room on the 3rd floor has cleaned on (12/20/2019). Quality review of facility front lobby, activities rooms and day rooms for cleanliness completed by Administrator/Designee by (01/17/2020). Follow up based on findings. Staff educated by RCDNS/Designee, the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Administrator/Designee will monitor weekly times 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the tour of the building, the facility failed to keep all areas of the building well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. The men?s common bathroom on the basement level had a strong smell of urine.
Plan of Correction:	The men's common bathroom on the basement level cleaned on (12/20/2019) and is now free of odor. Quality review of facility common bathrooms to ensure bathrooms are odor free completed by Administrator/Designee by (01/17/2020) Follow up based on findings. Staff educated by RCDNS/Designee, all buildings shall be well ventilated and free from foul, stale, and musty odors. Administrator/Designee will monitor weekly times 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-870-C
Description:	Based on observations made during the tour of the building, the facility failed to make adequate provisions for the collection of garbage. EVIDENCE: 1. The basement women?s common bathroom had a trash can that was observed to be full and overflowing with trash. 2. There was a large clear trash bag filled with trash sitting outside of the ?The Cozy Corner? downstairs in the common area of the basement.
Plan of Correction:	The basement women's common bathroom was cleaned on (12/20/2019). The large clear trash bags filled with trash from "The Cozy Corner" was discarded on (12/20/2019). Quality review of facility common bathrooms to ensure the trash is not overflowing completed by Administrator/Designee by (01/17/2020). Follow up based on findings. Quality review of facility common areas to ensure no full trash bags sitting around completed by Administrator/Designee by (01/17/2020). Follow up based no findings. Staff educated by RCDNS/Designee, adequate provisions for the collection and legal disposal of garbage, ashes, and waste material shall be made. Administrator/Designee will monitor weekly times 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to keep all furnishings, fixtures and equipment including furniture, window coverings, sinks, toilets, bathtubs, and showers clean and in good repair and condition. EVIDENCE: 1. The white cabinets in the kitchenette area of the basement level were stained on the corners with a black and brown substance. 2. The day room on the 3rd floor had white kitchen cabinets under the sink area that were scuffed. 3. The day room on the 2nd floor had white kitchen cabinets under the sink area that were scuffed.
Plan of Correction:	The white cabinets in the kitchenette area of the basement level cleaned as indicated on 01/10/2020. The white kitchen cabinets in the day room on the 3rd floor cleaned and painted as indicated on 01/10/2020. The white kitchen cabinets in the day room on the 2nd floor cleaned and painted as indicated on 01/10/2020. Quality review of kitchenette/kitchen cabinets for scuffs and stains completed by Administrator/Designee by (01/17/2020). Follow up based on findings. Staff educated by RCDNS/Designee , all furnishings, fixtures and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Administrator/Designee will monitor weekly times 12 weeks and as indicated thereafter [sic].
Standard #:	22VAC40-90-30-B
Description:	Based on review of staff records and sworn disclosures, the facility failed to ensure one new staff member completed a sworn disclosure statement for employment in a sample of five. EVIDENCE: 1. Staff # 7 was hired at the facility on 10/11/2019. The sworn disclosure for this staff member could not be located in her file and could not be produced by the facility on the day of inspection.
Plan of Correction:	Sworn disclosure statement for employment. Staff #7 completed a sworn disclosure statement for employment on (01/13/2020). Quality review of sworn disclosure statements for employment of other staff completed by Administrator/Designee by (01/17/2020). Follow up based on findings. RCDNS &ED educated by the RDCO, staff must complete a sworn disclosure statement for employment. Administrator/Designee will monitor each new hire times 3 months and as indicated thereafter. [sic]
Standard #:	22VAC40-90-40-B
Description:	Based on review of staff records and background checks, the facility failed to obtain the criminal history record report in or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff # 7 was hired at the facility on 10/11/2019. The criminal record history record report could not be located and was completed on the day of inspection which was 12/19/2019. This exceeds 30 days of employment.
Plan of Correction:	Criminal record history record report. Staff #7 criminal record history record report was completed on the day of inspection which was 12/19/2019, exceeding 30 days of employment. Quality review of criminal record history record reports of each staff completed by Administrator/Designee by (01/17/2020). Follow up based on findings. RCDNS & ED educated by the RDCO; facility must obtain the criminal history record report in or prior to the 30th day of employment. Administrator/Designee will monitor each new hire times 3 months and as indicated thereafter. [sic]