VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carrington Cottage Memory Care
270 Commons Parkways
Daleville, VA 24083
(540) 300-2412

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Aug. 10, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/10/2023 9:00am until 2:00pm 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: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to ensure that staff screenings for tuberculosis were completed as required. EVIDENCE: 1. The screening for tuberculosis dated 06/28/2023 in the records for staff 1, 2 and 5 did not contain the name or signature of the healthcare professional that completed the screenings.
Plan of Correction:	100% audit of TB screenings for completion with healthcare professional signature was completed with no new findings. Provided Business Office Manager with education surrounding complete and accurate tuberculosis screening documentation. Business Office Manager or designee to audit all new hires to ensure completion of TB screening, ensuring there is a healthcare professional signature.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview with staff, the facility failed to review and update the Individualized Service Plan (ISP) at least once every 12 months and as needed for a significant change of a resident?s condition. EVIDENCE: 1. The record for resident 6 has documentation that there is a physician?s order dated 07/13/2023 for home health to evaluate wound and assist with dressing. Documentation of a home health visit summary dated 07/20/2023 in resident 6?s record indicates that skilled nursing will come twice a week for several weeks, then once a week when wound is improving. An interview with staff 4 indicated that this resident was currently receiving home health services for wound care. The ISP dated 12/15/2022 in the record for resident 6 has not been updated to include the significant need of home health services for wound care.
Plan of Correction:	Record for Resident 6 corrected to reflect significant need for home health services. 100% audit of all residents receiving home health services to ensure ISP reflect the need and services provided has been completed with no new findings. Supervisory staff received education surrounding the importance of timely and accurate ISP updates. Resident Care Director or designee to review and audit all residents? ISPs receiving home health services.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and observations of the morning medication pass, the facility failed to ensure that medications were administered in accordance with physicians instructions. EVIDENCE: 1. During the morning medication pass on the Fincastle medication cart the LI observed the medication administration records (MARs) for resident 4 and noted a physician order for Metoprolol Succ ER 25mg, one tablet every day for hypertension * DO NOT CRUSH*. Staff 2 prepared the morning medications for resident 4 including the Metoprolol Succ ER 25mg and placed all medications in a plastic bag a began to place the bag in a pill crusher that was sitting on top of the medication cart. The LI stopped staff 4 from crushing the medications and asked staff 4 to review resident 4?s MAR again to prevent the Metoprolol Succ ER 25mg from being administered out-side of physician instructions.
Plan of Correction:	Staff #2 was immediately provided education following DSS Inspector?s observation. Nursing leadership provided individualized coaching and guidance through 1:1 medication pass observation for the remainder of the medication administration. 100% education completed with all staff performing medication administration. Medication administration audits will be completed on all licensed individuals permitted to administer medication.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that all required information was properly documented on resident medication administration records (MARs). EVIDENCE: 1. The record for resident 2 has documentation of a physician order dated 06/28/2023 for a Omnipod Dash 5 Pack apply as directed and change revery third day. The July 2023 MAR for resident 2 has documentation of the Omnipod Dash 5 pack being applied on 07/20/2023 by staff 2 and on 07/26/2023 by staff 5 but also has documentation on 07/23/2023 that the Omnipod Dash 5 Pack was ?physically unable to take, has been DC?d, no longer has the insulin pump? which was charted by staff 7. An interview with staff 4 indicated that the Omnipad Dash 5 pack was being applied by a home health agency until it was discontinued, and that facility staff were never responsible for the application.
Plan of Correction:	Order for Resident #2?s Omnipod has been discontinued. Provided licensed individuals responsible for medication administration with education regarding appropriate documentation. 100% audit of all residents receiving home health services to ensure documentation of services is recorded accurately and appropriately. Resident Care Director or designee to audit, monitor documentation of services, and ensure the resident?s individualized service plan accurately reflects those services provided by home health organizations.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. A container of Microdot Bleach Wipes, a can of Airlift Odor Eliminator and a bottle of febreeze April Fresh was observed sitting in the unlocked cabinets at the nursing station on the Troutville unit. The nursing station is an open area in the dining room and no staff were present at the time the cleaning supplies were observed.
Plan of Correction:	Listed items were immediately removed and stored in a locked area. All employees received education regarding importance of storing cleaning supplies in locked areas. 100% audit of community to ensure cleaning supplies are stored in locked area was completed with no new findings. Environmental service staff or designees to audit and monitor for unsecured cleaning supplies.
Standard #:	22VAC40-73-930-D
Description:	Based on record review, the facility failed to ensure that resident rounds are documented to include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. EVIDENCE: 1. The 2-hour checks for resident 1 were not documented as completed on 07/04/2023 at 4 AM and 6 AM and from 6 PM through 10 PM; on 07/10 from 12 AM through 6 AM; on 07/14 from 12 AM through 6 AM; on 07/26 from 12 AM through 6 AM; and on 08/05 at 10 PM. In addition, there is no indication on 08/04, 08/05, and 08/06 of which staff member performed the rounds on those dates.
Plan of Correction:	Direct care staff responsible for two-hour rounding were provided education regarding the importance of accurate documentation. Implemented 2 hour rounding binders and documentation requiring initials of staff to verify compliance. All direct care employees have received education regarding the new procedure. Resident Care Director or designee to audit 2 hour rounding binders for accuracy and completeness.
Standard #:	22VAC40-90-40-D
Description:	Based on staff record review, the facility failed to ensure that if a criminal history record is requested, that the employee has not been convicted of any of the barrier crimes. EVIDENCE: 1, The record for staff 3 hired on 06/28/2023 has documentation on the Criminal History Request Response dated 06/23/2023, that this staff member was found guilty of a misdemeanor barrier crime on 04/29/2019, which is within the last five years.
Plan of Correction:	Staff # 3 was immediately terminated from facility as an employee. Provided the facility?s Business Office Manager with education regarding the DSS standard for background checks, specifically barrier crimes within past 5 years. 100% audit of all employees background checks for barrier crimes disqualifying from employment was completed with no new findings. Business Office Manager or designee to audit background checks for new employees to ensure compliance.