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. 1, 2021

Complaint Related: No

Areas Reviewed:

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

Comments:

Two licensing inspectors conducted a one day unannounced mandated licensing monitoring inspection at Carrington Place at Wytheville on 12/1/2021. The inspection began at 10:40 am and concluded at 6:42 pm. During the 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 68 residents in care at the time of the inspection. An exit meeting was conducted with the administrator and other key staff on 12/1/2021 and at that time an opportunity was given to find items that were not available in files. As a result of this inspection 12 violations are being cited. Please develop a plan of correction for each cited violation along with a date of correction and return and signed and dated copy back to the licensing office within 10 calendar days (12/23/2021) of receipt. If you have any questions please contact your licensing inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on documentation review and the physical examination report, the facility failed to ensure the physical examination report contained all of the required information. EVIDENCE: 1. Resident # 1 was admitted to the facility on 08/01/2020. The physical examination report for resident # 1 dated 07/30/2020 did not indicate whether or not she is capable of self-administering medications. 2. Resident # 7 was admitted to the facility on 06/01/2021. The physical examination report for resident # 7 dated 5/13/2021 did not have a height listed. 3. Resident # 8 was admitted to the facility on 07/26/2021. The physical examination report for resident # 8 dated 7/21/2021listed the resident being allergic to Morphine and tape but did not list the description of reactions to these allergies.
Plan of Correction:	Resident # 1 physical examination report updated to specifying whether or no the resident is capable of self-administering medications was reviewed and indicated by physician on 12/2/21. Resident # 7 physical examination updated with height. Resident # 8 physical examination updated with description of reactions to identified allergies. Quality review of physical examination and reports for other residents for allergies and reactions, height and weight, and statement specifying whether the individual is or is not capable of self-administering medication completed by RCDNS/Designee on 12/2/21. Follow up based on findings. RMA's educated b y 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 teh assisted living facility and shall contain, and known allergies and description of the person's reactions, statement that specifies whether the individual is or is not capable of self-administering medication, and height and weight listed. RCDNS/Designee will monitor prior to admission times 3 months and as indicated thereafter. [sic]
Standard #:	22VAC40-73-530-B
Description:	Based on observations made during the tour of the physical plant and interviews with staff, the facility failed to ensure door leading to the outside shall not be locked from the inside or secured from the inside in any manner that amounts to a lock. EVIDENCE: 1. On the day of inspection the elevator within the facility was not working properly. The administrator stated "the elevator needs a part in order it that's going to cost $30,000 and approval has been made and there is a six week time frame for repair. She instructed staff on the day of inspection due to safety concerns to lock the elevator and accompany residents on the elevator when they want to go down to the second floor from the third floor or up to the second floor from the first floor. The elevator had not been working since Monday (3 days). Residents were not able to get on the elevator by themselves as staff would have to unlock the elevator with a key in order for them to be able to come and go". The stairwell on both the third and first floor were locked and a code is needed to open the door. The residents had not been given access to the code. This facility serves a mixed population. Resident were not able to come and go freely from the third and first floor to the second floor where dining and common areas are located. 2. The locked elevator and stairwell doors on the third and first floor leads to exterior doors to the outside on the second floor.
Plan of Correction:	On 12/1/21 the elevator was unlocked and was up and operational. Residents were then able to come and go freely. The part for permanent repair of the elevator has been ordered and facility is awaiting arrival of part so that repair can be completed. Quality review of elevator to be unlocked and to be functioning was completed by RCDNS/Designee on 12/01/21. Follow up based on findings. Staff education by Administrator/Designee that door leading to the outside shall not be locked form teh inside or secured form the inside in any manner that amount to a lock, except that doors may be locked or secured n a manner that amount to a lock in special care units as provided in 22VAC40-73-1150A. Administrator/Designee will monitor weekly times 12 weeks and as indicated thereafter. Elevator company will come weekly and inspect elevator for safety until permanent repairs are made. [sic]
Standard #:	22VAC40-73-560-E
Description:	Made on observations made during the tour of the building, the facility failed to keep all resident records in a locked area. EVIDENCE: 1. Resident files are kept in room # 164. The door was observed to be propped open with no staff present inside the room. The room was observed to be unlocked and unattended for the duration of the inspection from 10:40 am until 6:42 pm.
Plan of Correction:	Sign was placed on the medical room #164 on 12/1/21. Quality review of medical record room for it to be locked and closed at all times when not in use completed by Administrator/Designee by 12/1/21. Follow up based on findings. Staff educated by RCDNS/Designee, all resident records shall be kept current, retained at the facility, and kept in locked area. Administrator/Designee will monitor weekly for 12 weeks and indicated thereafter. [sic]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the tour of the building, the facility failed to date the posted menu. EVIDENCE: 1. The menu posted on the bulletin board in the entrance area to the facility did not contain dates, only the days of the week.
Plan of Correction:	Adding dates to the posted weekly menu on the front lobby was completed on 12/2/21. Quality review of weekly posted menu for dates completed by Administrator/Designee by 12/2/21. Follow up based on findings. Staff educated by Administrator/Designee, menus and snacks for current weeks shall be dated and posted in an area conspicuous to residents. Administrator/Designee will monitor weekly times 12 weeks and as indicated thereafter.[sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the audit of the medication carts, the facility failed to adhere to their medication management plan regarding methods to prevent the use of outdated, damaged, or contaminated medications and to ensure that each resident's prescribed medications and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missing doses. EVIDENCE: 1. Resident # 14 had Proair AFA inhaler, Lantus 100 units, and Novolin flex pen located in Med Cart # 1. None of these medications had an open date documented on the packaging. 2. Resident # 15 had Advair Disk inhaler located in Med Cart # 1. This medication did not have an open date documented on the packaging. 3. Resident # 16 had Ventolin HFA Inhaler located in Med Cart # 1. This medication did not have an open date documented on the packaging. 4. Resident # 17 has Ozempic .25-.5 located in Med Cart # 1. This medication did not have an open date documented on the packaging. 5. Resident #18 had Levemir 43 units located in Med Cart # 1. This medication did not have an open date documented on the packaging. 6. Resident # 18 is prescribed Furosemide 40 mg, take one tablet daily by mouth started on 5/4/2021. This medication was not available on the medication cart. 7. Resident # 18is prescribed Lantanprost 0.005% apply one drop in each eye at bedtime started on 12/3/2020, this medication was not available on the medication cart. 8. Resident # 18 is prescribed Stimulant Laxative Plus 8.6-50mg, administer one tablet by mouth at bedtime started on 12/7/2020, this medication was not available on the medication cart.
Plan of Correction:	Resident # 14 Proair Inhaler, Lantus and Novolin Pen has open date documented on the packaging . Resident # 15 Advair Disk Inhaler has an open date documented on packaging. Resident # 16 Ventolin HFA Inhaler has an open date documented on the packaging. Resident # 17 Ozempic has open date documented on the packaging. Resident # 18 Levemir has open date documented on the packaging. Resident # 18 received Furosemide 40 mg, Lantaprost 0.005% eye drops and Stimulant Laxative Plus 8.6-50 mg on 12/1/21 from the pharmacy per manifest. MD notified on 12/1/21 of medications for resident # 18 not being available. No new orders received. No adverse reaction noted to resident # 18 of not receiving 9 am doses of Furosemide and Stimulant Laxative Plus. Quality review of documented open dates on all packaging and medication availability and available on medication cart for other residents completed by RCDNS/Designee by 12/24/21. Follow up based on findings. RMA's educated by RCDNS/Designee that medication ordered for administration shall be available, properly labeled for specific residents, and properly stored at the facility. RCDNS/Designee will monitor weekly times 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on observations made during the 1pm medication pass, the facility failed to have a physician's or other prescriber's order for the change to a medication. EVIDENCE: 1. Resident # 12 is prescribed Neurontin 300 mg, one tablet by mouth three times daily, Ropinirole 1 mg tablet by mouth three times daily , and Bumetandine 2 mg tablet by mouth daily. 2. When staff # 2 went to administer these medications, Resident # 12 requested these medications be administered in her applesauce. Staff # 2 went back to the medication cart to get applesauce and proceeded to administer resident # 12's medications in applesauce. There was no physician's or other prescriber's order available available in the facility stating that these medications could be administered in applesauce.
Plan of Correction:	Resident # 12's physician was contacted and an order was received that states medications may be administered in applesauce. Quality review of all resident's physicians orders for a current order that medication may be administered with applesauce completed by 12/22/21. Follow up based on findings. Staff educated by RCDNS/Designee, that no medications, dietary supplements, 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 prescriptions, over the counter and sample medications. Administrator/Designee will monitor weekly for 12 weeks and indicated thereafter. [sic]
Standard #:	22VAC40-73-660-A
Description:	Based on observations made during the medication cart audit, the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice. EVIDENCE: 1. Staff # 2 was assisting both licensing inspectors in auditing the medication cart. During audit staff # 2 walked away form the cart from 4:28 pm to 4:38 pm to assist a family member of a resident. The medication car was unlocked and unattended during that time. The keys were left in the cart and the medications the licensing inspectors were reviewing were left on top of the medication cart.
Plan of Correction:	All medications were secured inside medication carts and all medication carts were locked on 12/1/21. Quality review of all medications being secure and all medication carts being locked was completed by Administrator/Designee by 12/1/21. Follow up based on findings. Staff # 2 was counseled by RCDNS that medication cart must be locked when unattended and keys to the cart must be on her person. RMA's educated by RCDNS/Designee, medications, shall be stored in a manner consistent with current standards of practice; the storage area shall be locked, the individual responsible for medication administration shall keep the keys ti the storage area on his person. Administrator/Designee will monitor weekly for 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the review of resident records and Medication Administration Records (MARs), the facility failed to ensure that medications shall be administered in accordance with Physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident # 12 had 12 of 18 medications/treatments, resident # 7 had three of seven medications/treatments, resident # 18 had eight out of 19 medications/treatments, resident # 10 had five out of 11 medications/treatments, resident # 13 had 17 out of 29 medications/treatments that were documented as administered on time but were not charted on the MAR until three to five hours after the medications were administered. 2. Resident # 18 is prescribed Enulose 15 mL, administer 15 mL by mouth twice daily which started on 2/5/2020. Staff # 3 stated this medication was not available on the medication cart for Resident # 18, but she had been administering this medication as prescribed as she stated she was borrowing the dose form another resident because Resident # 18 had been out of this medication for approximately three to four days.
Plan of Correction:	Statements received from staff # 2 and staff # 3 that medications for resident(s) # 12, 7, 18, and 13 did receive their medications on time on 12/1/21 per physician order. Resident # 18 Enulose arrived on 12/1/21 via the pharmacy manifest. Quality review of medication documentation and medication availability for other residents completed by Administrator/Designee by 12/24/21. Follow up based on findings. Staff # 3 was counseled by RCDNS/Designee regarding the borrowing of medications from one resident to administer to another is not allowed. RMA's educated by RCDNS/Designee that at the time medication is administered, the facility shall document on medication administrator record (MAR) for all medications administered to the residents, including over-the-counter medications and dietary supplements. RMA's educated by RCDNS/Designee that medications ordered shall be available, properly labeled for specific resident and stored at the facility and regarding the borrowing of medications from one resident to administer to another resident is not allowed. 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 noon medication pass and review of resident records, the facility failed to include the diagnosis on the Medication Administration Record (MAR). EVIDENCE: 1. Resident # 7 had the following medications prescribed by a physician or other prescriber and listed on the MAR; the MAR did not contain a diagnosis for these medications: B-12 shots, Ferrous Sulfate, Miralax, Pepcid, Tylenol, and Senna. 2. Resident # 12 had the following medications prescribed by a physician or other prescriber and listed on the MAR; the MAR did not contain a diagnosis for these medications: Accuchecks and Cetaphil. 3. Resident # 10 had the following medications prescribed by a physician or other prescriber and listed on the MAR; the MAR did not contain a diagnosis for these medications: Vitamin D2, Protonix, Metoprolol Succinate, Mematine, Lisinopril, Latanoprost, Donepezil, Crestor, Dilantin, Amlodipine, and Clonidine. 4. Resident # 18 had the following medications prescribed by a physician or other prescriber and listed on the MAR; the MAR did not contain a diagnosis for these medications: Enulose, Antifungal powder, Stimulant Laxative Plus, Novolog Flexpens, Metoprolol Succinate, Melatonin, Levothyroxine, Levemir Flextouch, Lantaprost, Ketotifen Furmate, Enulose, Eliquis, and Bumetanide. 5. Resident # 13 had the following medications prescribed by a physician or other prescriber and listed on the MAR; the MAR did not contain a diagnosis for the following medications: Gabapentin, Furosemide, Dicyclomine, Hydrocodone-Acetaminophen, Glipizide, Lorazepam, Lisinopril, Potassium Chloride, Metoprolol, Tapazole, Questran, Aspercreme with aloe, and Anti-Dandruff Shampoo.
Plan of Correction:	Resident # 7 MAR updated with diagnosis for all medications. Resident # 12 MAR updated with diagnosis for all medications. Resident # 10 had been discharged from the facility on 12/9/21 and record has been closed. Resident # 18 MAR updated with diagnosis for all medications. Resident # 13 MAR updated with diagnosis for all medications. Quality review for resident(s) MAR(s) for all medications to have a diagnosis for the indication of administering medication complete by Administrator/Designee by 1/1/22. Review for diagnosis will be completed upon new admission and upon receiving new physician orders. Follow up based on findings. RMA's educated by RCDNS/Designee, that the MAR shall include diagnosis, condition, or specific indications for administering the drug or supplement. Administrator/Designee will monitor weekly times 12 weeks and indicated thereafter. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during the tour of the building, the facility failed to keep all hazardous materials and cleaning supplies in a locked area. EVIDENCE: 1. On the 3rd floor in the Day Room there is a housekeeping closet, the door to this closet was observed to be propped open with a cleaning rag and unattended. 2. The closed contained a 2.5 liter bottle of Diversey Stride Floral AC Neutral Cleaner. The label on the cleaner says "causes burns/serious damage to mouth, throat, and stomach". 3. Before Licensing Inspector left the Day Room, she removed the cleaning rag form the door to rectify the hazard.
Plan of Correction:	Housekeeping closed in the 3rd floor day room was closed and locked on 12/1/21. Quality review of 3rd floor housekeeping closet for it to be locked and closed completed by Administrator/Designee by 12/2/21. Follow up based on findings. Housekeeper that assigned to the 3rd floor on 12/1/21 was counseled by the housekeeping supervisor on 12/2/21. Staff educated by RCDNS/ Designee that each facility shall store cleaning supplies and other hazardous materials in a locked area. RCDNS/Designee will monitor weekly for 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to keep all areas of the building clean and in good repair. EVIDENCE: 1. On the 3rd floor in the Day Room, there was a water leak residue stain that was approximately one foot wide above the Christmas Tree, the kitchenette in this area had dried coffee drippings down the front of the white under sink cabinet areas. 2. The common bathroom in the Day Room on the 3rd floor had the odor and appearance of human feces in the sink as well as on three paper towels located on the garbage can under the sink.
Plan of Correction:	The water stain in the day room on the 3rd floor cleaned and painted on 12/20/2021. The common bathroom in the 3rd floor day room was cleaned on 12/1/21 and is now free of odors. The kitchenette area in the 3rd floor dayroom was cleaned on 12/2/21 and is now free of stains. Quality review of facility common bathrooms and day rooms for cleanliness completed by Administrator/Designee by 12/20/21. 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 odor. Administrator/Designee will monitor weekly times 12 weeks and as indicated thereafter. [sic]
Standard #:	22VAC40-73-980-A
Description:	Based on observations made during the audit of the first aid kit, the facility failed to have all items required by standards included. EVIDENCE: 1. The LI observed two first aid kits on the 2nd floor. The kits did not contain disposable single use waterproof gloves, hand cleaner, or tweezers.
Plan of Correction:	Added to the first aid kits on 12/1/21 was disposable single use waterproof gloves, hand cleaner, and tweezers. Quality review of first aid for all equipment present completed by Administrator/Designee by 12/1/21. Follow up based on findings. Staff educated by RCDNS/Designee, first aid kits will be checked monthly to ensure that all items are present. First aid cart will be secured with a zip tie to quickly indicate that the cart has been accessed and for a need to review the car that all equipment is present. Administrator/Designee will monitor monthly and as needed for 3 months and indicated thereafter. [sic]