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: Jan. 24, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/24/2023, 9:45am ? 7:53pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at (276) 608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observations made during the morning medication pass, the facility failed to implement an infection control program consistent with the federal Center for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations. EVIDENCE: 1. When staff #6 checked blood glucose levels for resident #10 and resident #11, she did not place a protective barrier down on the medication cart prior to placing the glucose monitoring device down.
Plan of Correction:	By 3-3-2023 RCD or designee will complete inservice education with all nursing staff and medication technicians to ensure safe and proper handling of glucose monitoring devices. RCD or designee will monitor weekly for four weeks on all shifts to ensure compliance. [SIC]
Standard #:	22VAC40-73-50-B
Description:	Based on a review of resident records, the facility failed to obtain written acknowledgement of the receipt of the disclosure statement by the resident or his legal representative, for three of the nine resident records reviewed. EVIDENCE: 1. There were no written acknowledgements of the receipt of the disclosure statement found in the records for resident #3, admitted on 02/02/2022, resident #6, admitted on 09/15/2021, and resident #9, admitted on 07/26/2021.
Plan of Correction:	By 3-3-2023 an audit will be completed of all AL resident charts to ensure confirmation of receipt of disclosure statement has been completed, including for resident #3, #6 and #9. RCD or designee will audit new resident charts monthly for four months to ensure compliance. [SIC]
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to obtain an initial tuberculosis examination and report for one of the five staff records reviewed. EVIDENCE: 1. Staff #3 started work on 01/04/2023; there were no results of a risk assessment, documenting the absence of 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, found in the record for staff #3.
Plan of Correction:	By 3-3-2023 all current staff charts will be audited to ensure risk assessments have been completed and remains in the staff member?s file, including staff member #3. Audits will be completed for each new staff member to confirm compliance weekly for twelve weeks. [SIC]
Standard #:	22VAC40-73-290-A
Description:	Based on a review of the facility written work schedules, the facility failed to provide an indication of whomever is in charge at any given time. EVIDENCE: 1. The December 2022 and January 2023 written work schedules do not indicate the staff person in charge at any given time.
Plan of Correction:	By 2-15-2023 all printed work schedules will indicate person in charge on each shift. A monthly audit will be completed by RCD or designee to ensure compliance for three months. [SIC]
Standard #:	22VAC40-73-290-B
Description:	Based on observations made during the tour of the building, the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place that is conspicuous to the residents and the public. EVIDENCE: 1. LI did not observe the on-site person in charge posting during the tour of the facility. When the LI asked the front desk staff how the general public and residents know who is in charge she stated ?I don?t know, I?ve never been asked that question before?.
Plan of Correction:	On 2-8-2023 a written display will be placed at the reception desk to reflect the person in charge. By 3-3-2023 education will be provided to all staff, including front desk staff, on how to use the visual to update and identify the person in charge. Audits will be completed weekly for four weeks at different hours to ensure the person in charge is posted. [SIC]
Standard #:	22VAC40-73-310-B
Description:	Based on a review of resident records, the facility failed to maintain verification of a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual resident and his or her legal representative, if any, for one of the nine resident records reviewed. EVIDENCE: 1. Resident #3 was admitted to the facility on 02/02/2022 and there was no verification/acknowledgement of the required interview.
Plan of Correction:	By 3-3-2023 an audit will be completed of all AL resident charts to ensure verification/acknowledgement of required admission interview has been completed, including resident #3. RCD or designee will audit new resident charts monthly for four months to ensure compliance. [SIC]
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to obtain a complete physical examination and report for two of the nine resident records reviewed. EVIDENCE: 1. The report of resident physical examination for resident #2, dated 06/27/2022, does not include a statement that specifies whether the individual is considered to be ambulatory or nonambulatory; that particular section was found to be blank. 2. The report of TB screening form for resident # 9, dated 09/12/2022, is signed by an MD/designee, but there is no indication of TB status; that section of the form was found to be blank.
Plan of Correction:	By 3-3-2023 an audit will be completed of all AL resident charts to ensure ambulatory statuses and TB screenings are completed. RCD or designee will audit new resident charts monthly for four months to ensure compliance. [SIC]
Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to obtain complete personal and social information for one of the nine resident records reviewed. EVIDENCE: 1. The resident personal/social data form for resident #3, dated 02/02/2022, is only partially completed; several areas are blank, including the following: marital status, birth place, interests/hobbies, lifetime vocation, career or primary role, service in the armed forces, if applicable, information on advance directives, Do Not Resuscitate (DNR) orders, or organ donation, if applicable, legal representative, if any, address and phone of designated contact person, last name, address and phone of responsible individual, clergyman/place of worship, if applicable, next of kin, if known, personal physician, personal dentist, local department of social services, if applicable, previous mental health or intellectual disability services history, if any, and if applicable for care and services, current behavioral and social functioning, including strengths and problems, and substance abuse history if applicable for care or services.
Plan of Correction:	By 3-3-2023 an audit will be completed of all AL resident charts to ensure personal/social data forms are completed entirely, including resident #3. An audit will be completed for new residents monthly by the RCD or designee to ensure personal/social data forms are completed for all residents. [SIC]
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records, the facility failed to ensure complete Uniform Assessment Instruments (UAIs) for three of the nine resident records reviewed. EVIDENCE: 1. The UAI dated 03/24/2022 in the record for resident #5 is only partially filled out. Several areas including entire pages of the UAI are not complete. 2. The UAI dated 11/16/2022 in the record for resident #7 is only partially filled out. Several pages are completely blank. 3. The UAI dated 02/04/2022 in the record for resident #8 is only partially filled out. Several pages are completely blank.
Plan of Correction:	By 3-3-23 an audit will be completed of all AL resident charts to ensure UAI forms are completed entirely, including residents #5, #7 and #8. Administrator and RCD will request a UAI ?short form? is completed for renewals to ensure all information is recorded. An audit will be completed monthly on new residents and resident renewals by the RCD or designee to ensure UAIs are completed entirely for all residents. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on Individualized Service Plans (ISP?s) for three of nine resident files that were reviewed. Additionally, the facility failed to update the time frame for expected outcome on ISPs for three of nine resident files that were reviewed. EVIDENCE: 1. The UAI dated 06/29/2022 in the record for resident #2 identifies transportation and shopping as areas in which the resident needs help, as well as short term memory loss. The ISP dated 07/29/2022 in the record for resident #2 does not address these needs. 2. The UAI dated 01/26/2022 in the record for resident #3 identifies meal preparation as an area in which the resides needs help. The ISP dated 02/28/2022 in the record for resident #3 does not address this need. 3. The UAI dated 09/27/2022 in the record for resident #4 identifies toileting, meal preparation, housekeeping, laundry and money management as areas in which the resident needs help, as well as short term and long term memory loss and judgement problems. The ISP dated 11/30/2022 in the record for resident #4 does not address these needs. 4. The ISP reviewed and signed on 05/29/2022 in the record for resident #5 does not have updated time frames for any of the identified needs. 5. The ISP reviewed and signed on 10/24/2022 in the record for resident #6 does not include time frames for 10 of the identified needs and does not have updated time frames for 2 of the identified needs. 6. The ISP reviewed and signed on 01/17/2023 in the record for resident #7 does not include a time frame for 1 of the identified needs and does not have updated time frames for 5 of the identified needs.
Plan of Correction:	By 3-3-23 all resident ISPs will be audited to ensure accuracy. ISPs will be audited monthly for four months on residents who have had a change in condition or have had service changes. [SIC]
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to ensure Individualized Service Plans (ISPs) are reviewed and updated at least once every 12 months for two of the nine resident records reviewed. EVIDENCE: 1. The ISP reviewed in the record for resident #8 has not been updated since 11/16/2020. 2. The ISP reviewed in the record for resident #9 has not been updated since 08/24/2021.
Plan of Correction:	By 3-3-23 all resident ISPs will be audited to ensure each is up to date, including residents #8 and #9. ISPs will be audited monthly for four months on residents who have had a change in condition or have had service changes. [SIC]
Standard #:	22VAC40-73-490-A-3
Description:	Based on staff interview and record review, the facility failed to ensure all residents be included at least annually in health care oversight. EVIDENCE: 1. The last health care oversight provided for the residents in this facility was dated October 2021. 2. LI asked staff #2 if the facility had a more recent oversight. Staff #2 stated October 2021 was the most up to date documentation the facility had of the health care oversight.
Plan of Correction:	By 3-3-2023 Q1 health care oversight will be completed. Administrator, RCD or designee will monitor compliance quarterly in February, May, August and November 2023. [SIC]
Standard #:	22VAC40-73-560-E
Description:	Based on observations made during the tour of the building, the facility failed to keep all resident records in a locked area. EVIDENCE: 1. On the first floor of the building, the LI observed room #164 to be unlocked and unattended from 11:14am-11:25am. Room #164 was observed to contain resident medical files. 2. On the second floor of the building, the LI observed the ?Narc Book Cart 2 #1 Room #25?260? sitting on top of medication cart #1 unattended from 12:35pm-12:45pm. This book contained resident names and other confidential information.
Plan of Correction:	By 3-3-23 HIPPA education will be provided to all staff to cover the following; how to properly safeguard resident medical files and proper storage of the narcotic book. RCD or designee will conduct audits x3 per week for four weeks at different times to ensure compliance with narcotic book storage. [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 (MMP). EVIDENCE: 1. According to the facility?s MMP (page 7), number two under Medication Disposition it states, ??medications that are expired, discontinued?will be stored in a separate area from currently used medications until properly disposed.? Number three states ??medications may be destroyed?or returned to the pharmacy within 90 days of the?discontinuation??. 2. Resident #11 had Loperamide 2mg, two by mouth every eight hours as needed for three days. This medication had been discontinued by a physician?s order dated 11/03/2022; this medication was still stored on the first-floor medication cart with resident #11?s other medication. 3. Resident #12 had Fluticasone two sprays in each nostril, Mirtazapine 7.5 mg one tablet by mouth at bedtime, and Ondansetron 8mg one tablet by mouth every eight hours for days one-five of chemotherapy by mouth. These three medications were discontinued upon his admission from the skilled nursing side of the building to the assisted living side of the building on 01/04/2023. These medications were still being stored on the first-floor medication cart with Resident #12?s other medications. 4. Resident #2 had a physician?s order to discontinue Preservision Areds, one by mouth two times daily dated 12/21/2022. This medication was still being stored on the first-floor medication cart with Resident #2?s other medications.
Plan of Correction:	On 2-8-23 all expired medications were removed from the medication carts. An audit will be conducted of all medication carts to ensure all medications are unexpired weekly for four weeks by the RCD or designee. Medication Disposition education will be provided to nurses and medication technicians by 3-3-2023. [SIC]
Standard #:	22VAC40-73-650-A
Description:	Based on staff interview and resident observations made during the medication cart audit, the facility failed to have a valid physician?s order to change or discontinue a medication. EVIDENCE: 1. Resident #11 has a physician?s order for Flonase Allergy Relief 50mcg two sprays bilaterally intranasal every night one time a day. The order was signed and was to begin on 01/17/2023 and to be discontinued on 01/31/2023. 2. Staff #6 confirmed the medication had been ordered by the physician on 01/24/2023 but it was not located on the medication cart, not available to Resident #11 and had not been filled by the pharmacy on the date of the inspection.
Plan of Correction:	By 3-3-2023 an audit will be completed of all resident MARs to ensure all current medications are available. The RCD will complete monthly audits of all resident MARs for four months to ensure compliance. [SIC]
Standard #:	22VAC40-73-660-B
Description:	Based on observations made during the morning medication pass and review of resident records, the facility failed to ensure that medications are only kept in resident rooms when a resident is assessed as being able to self-administer their own medications. EVIDENCE: 1. The LI observed staff #6 administer morning medications to resident #8 on the day of inspection. 2. While in the room observing the medication pass, the licensing inspector observed a tube of Ammonium Lactate 12% cream, Clotrimazole cream, and Lotrimin Anti-Fungal cream sitting on top of the resident?s bedside table. 3. The Uniform Assessment Instrument (UAI) for Resident #8 documents that medications will be administered by facility staff and the record for this resident did not have a physician?s order for the resident to self-administer these medications.
Plan of Correction:	By 2-15-2023 an audit will be completed to ensure medications are only present in rooms of residents with a UAI and orders that indicate the resident is able to self administer medications. An audit will be completed weekly for four weeks by the RDC or designee to ensure medications are only in appropriate rooms. [SIC]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the building, the facility failed to ensure hot water at taps available to residents is maintained within a temperature range of 105-120 degrees Fahrenheit. EVIDENCE: 1. In the room for resident #3, the hot water at the bathroom sink reached a temperature of 121.8 degrees Fahrenheit. 2. The women?s common bathroom on the first floor had a hot water temperature of 124.4 degrees Fahrenheit. 3. The men?s common bathroom on the first floor had a hot water temperature of 124.5 degrees Fahrenheit.
Plan of Correction:	On 2-9-2023 an adjustment was made to the water tank to lower the water temperature in the women?s common bathroom, the men?s common bathroom and resident #3?s room. The temperatures once the adjustment was made were; 118, 119 and 119. An audit of four random rooms will be completed by the Administrator, Maintenance Director or designee weekly for four weeks to ensure proper water temperatures. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to ensure the interior of all buildings are kept clean and free of rubbish. EVIDENCE: 1. The third floor resident laundry area was found to be cluttered, with several garbage cans, durable medical equipment items, an old television and a food tray with leftover food and dirty dishes on it.
Plan of Correction:	By 2-17-2023 the third floor resident laundry area will be cleaned of all clutter and unused DME. The television will be relocated. Dirty dishes and leftover food were removed from the area on the same day of inspection. An audit will be completed by the Administrator, RCD, or designee weekly for four weeks to ensure the room is in neat order. [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to ensure all furniture is kept in good repair and condition. EVIDENCE: 1. The couch and chair in the third floor resident den appear worn, with peeling upholstery and sagging/indentations in the seats and backs.
Plan of Correction:	By 3-3-2023 furniture in the third floor resident den in poor repair will be disposed of with a plan to provide new furniture by 7-1-23. [SIC]
Standard #:	22VAC40-73-920-C
Description:	Based on observations made during the tour of the building, the facility failed to ensure ventilation to the outside in order to eliminate foul odors in all bathrooms. EVIDENCE: 1. In resident room #371, the bathroom exhaust fan did not appear to be in working order as it made no sound when switched on.
Plan of Correction:	By 2-17-2023 repairs will begin to the exhaust fan in resident room #371. Administrator, Maintenance Director or designee will conduct an audit of all resident rooms by 3-3-23 to ensure all exhaust fans are in working order. RCD or designee will conduct random audits monthly for 2 months to ensure fans remain in working order. [SIC]