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: April 12, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/12/2023, 11:35am to 1:05pm and 05/01/2023, 10:35am to 10:40am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/17/2023 regarding allegations in the area(s) of: Resident care and related services, medication administration Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. N/A 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 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on interviews with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of one resident. Evidence: 1. On 03/17/2023 at 3:34pm, resident #1 contacted the LI via phone and reported she had been administered the wrong medications at 5:30am the same date. Resident #1 reports the medications should have been administered to her roommate and noted she (resident #1) self-administers her own medications. 2. Resident #1 was unable to recall the name of the employee who administered the medications. 3. Resident #1 reports the medications included ?potassium, a vitamin and two pain pills." 4. Staff #1 and staff #2 verified that resident #1 did receive another resident's medications.
Plan of Correction:	By 6.1 re-education will be provided to all med techs and nurses on identifying residents using photos and by confirming the resident?s identity verbally. An audit will be completed to ensure photos are up to date by 6.1. [SIC]
Standard #:	22VAC40-73-70-C
Complaint related:	Yes
Description:	Based on interviews with staff, the facility failed to submit a written report to the regional licensing office within seven days regarding an incident involving a medication error that threatened the life, health, safety or welfare of one resident. Evidence: 1. On 03/17/2023 at 3:34pm, resident #1 contacted the LI via phone and reported she had been administered the wrong medications at 5:30am the same date. Resident #1 reports the medications should have been administered to her roommate, and noted she (resident #1) self-administers her own medications. 2. Resident #1 was unable to recall the name of the employee who administered the medications. 3. Resident #1 reports the medications included ?potassium, a vitamin and two pain pills? and stated, ?I took every one of them.? 4. Resident #1 reports she notified staff #2 after this incident occurred; staff #2 confirms she was notified by resident #1 regarding the incident. Staff #1 and staff #2 report the staff member who administered the medications was an agency provided employee. 5. Staff #2 reports the medications administered mistakenly to resident #1 were potassium 20mg tablet, vitamin B complex caplet, gabapentin 40mg capsule and ropinirole 2mg tablet. 6. Staff #1 and staff #2 report resident #1?s provider was notified regarding the incident and resident #1 was monitored with no adverse reactions noted. 7. A written report regarding this incident was not provided to the regional licensing office within seven days of its occurrence. 8. Staff #1 shared a copy of an ?Initial Assisted Living Incident? report with the LI on the date of inspection (04/12/2023), but both staff #1 and staff #2 confirm the incident was not reported by the facility to the regional licensing office prior to this date.
Plan of Correction:	A written report will be submitted to the regional licensing office within seven days regarding any adverse event that threats life, health, safety or welfare of resident(s). [SIC]
Standard #:	22VAC40-73-680-J
Complaint related:	Yes
Description:	Based on interviews with staff, the facility failed to ensure medication administration staff documented actions taken in one resident?s record regarding a medication error. Evidence: 1. Resident #1, staff #1 and staff #2 report resident #1 was mistakenly administered medications that should have been administered to her roommate on the morning of 03/17/2023 by an agency provided employee. 2. Staff #1 and staff #2 report resident #1?s provider was notified regarding the incident and resident #1 was monitored with no adverse reactions noted. 3. Staff #2 confirms the medication error nor any actions taken were documented in the record for resident #1.
Plan of Correction:	By 6.1 re-education will be provided to facility staff on documenting actions taken regarding a medication error. [SIC]