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: Dec. 13, 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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/13/2023 8:30am until 2:30pm 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: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed:3 Number of interviews conducted with residents: 1 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 #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interviews, the facility failed to ensure that direct care staff received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff 1, employed on 10/09/2023 did not contain documentation that the employee has received certification in first aid. An interview with staff 6 was conducted on the day of inspection in which staff 6 expressed that staff 1 has not received certification in first aid.
Plan of Correction:	Staff #1 was immediately removed from schedule pending updated first aid certification following DSS Inspector?s observation. BOM scheduled first aid and CPR course for certification renewals. 100% audit completed with no additional first aid certification discrepancies found. Certification audits will be completed on all licensed individuals on a quarterly basis.
Standard #:	22VAC40-73-310-B
Description:	Based on resident record review, the facility failed to ensure that an interview was documented between the administrator or designee and the resident and/or legal representative prior to admission. EVIDENCE: 1. The record for resident 2, admitted on 11/20/2023 and resident 3, admitted on 10/11/2023, did not contain documentation of an interview completed prior to admission with the facility Administrator or designee and the resident and/or their legal representative.
Plan of Correction:	DSS Inspector provided education to Administrator on requirement of documented interview between Administrator and designee and resident and/or legal representative prior to admission. Form created to document interview between Administrator or designee and resident and/or legal representative prior to admission. 100% education completed with Admissions, Administrator and all potential designees on requirement of documented interview. Documented interview will be completed for all admissions moving forward. Admissions will be audited quarterly for compliance.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to ensure that a fall risk rating was completed after a fall for residents who assessed as assisted living level of care. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 03/17/2023 in the record for resident 1 has documentation that the resident is assessed as assisted living level of care. Charting notes in resident 1?s record has documentation of the resident falling/being found on the floor on 09/05/2023 and 10/25/2023. The record for resident 1 did not contain documentation of a fall risk rating being completed for the falls on these dates.
Plan of Correction:	UAI for Resident #1 to reflect falling/being found on floor incident for 9/5/23 and 10/25/23. 100% audit of all Residents? incurring a falling episode/being found of floor to ensure documentation is present on ISP and in Resident?s medical record. Resident Care Director received education surrounding the importance of timely and accurate ISP updates and documentation in Resident?s medical record of incidents of falling/being found on the floor. Resident Care Director or designee to review fall incidents/being found on floor and update medical record/ISP in a timely manner. Resident care director or designee to audit occurrences monthly for compliance.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were signed and dated by the resident or their legal representative. EVIDENCE: 1. The ISP completed on 10/10/2023 in the record for resident 5 does not have documentation of the resident of their legal representatives signature. 2. The ISP completed on 08/15/2023 In the record for resident 6 does not have documentation of the resident of their legal representatives signature.
Plan of Correction:	ISP for Residents #5 and #6 were emailed to legal representative for notice and acknowledgement. 100% audit of all Resident?s ISP to ensure documentation of notice and acknowledgement completed. Resident Care Director, Administrator, and BOM received education surrounding the importance of timely notice and acknowledgement of ISPs from Resident or Resident legal representative by surveyor. Administrator or designee to review Residents? ISPs for notice and acknowledgement of ISPs when updated or created. Administrator or designee will audit ISP notice and acknowledgement monthly for compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized services plans (ISPs) were reviewed updated as needed for a change in resident condition. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 10/10/2023 in the record for resident 3 has documentation that the resident requires physical assistance with walking. The ISP dated 10/11/2023 does not have documentation to address this identified need.
Plan of Correction:	ISP for Resident #3 corrected to reflect the Resident?s need for physical assistance with walking. 100% audit of all Resident?s UAI and ISP to ensure needs and services were accurately reflected and coinciding on both records. Resident Care Director received education surrounding the importance of timely and accurate ISP/UAI updates. Resident Care Director or designee to review all residents? ISPs on admission, with changes in conditions and annually for accuracy. Resident Care Director will audit ISP/UAI monthly for compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication carts, the facility failed to implement their medications management plan (MMP) in regard to methods to prevent the use of outdated medications. EVIDENCE: 1. The facility MMP has documentation under Med04-Medication Storage 5. ?All multidose items shall have an open/start date. This includes creams, topicals, eye drops, ear drops, respiratory meds, powders, liquids, insulins and nitroglycerin?. 2. The Fincastle medication cart contained a Glargine Solostar insulin pen in the cart for resident 8 that did not have an open date. Instructions on the pharmacy label state ?Refrigerate until open, then 28 days at room temperature?.
Plan of Correction:	Glargine Solostar insulin pen was immediately and properly disposed following DSS Inspector?s observation. Resident Care Director educated on facility?s medication management policy and pharmacy recommendations for insulin pen storage. 100% audit on insulin pen storage performed with no additional improperly stored or labeled insulin pens noted. 100% education completed with all staff qualified to perform medication administration on appropriate insulin pen storage and labeling. Medication cart audits will be completed monthly to ensure insulin pens are stored and labeled appropriately for compliance
Standard #:	22VAC40-73-680-G
Description:	Based on observations of the facility medication carts, the facility failed to ensure that all over-the-counter medications were labeled with a residents name. EVIDENCE: 1. A box of Ayr Saline Nasal Rinse Kit was noted in the Fincastle medication cart and did not contain a resident name.
Plan of Correction:	Box of referenced Ayr Saline Nasal Rinse Kit was immediately labeled with appropriate Resident?s name following DSS Inspector?s observation. Administrator provided individualized education regarding Resident medications and treatment containers labeled with Resident specific information by surveyor. 100% audit on medication carts performed with no additional non labeled medications or treatments found. 100% education completed with all staff qualified to perform medication administration on labeling medication and treatments appropriately. Medication cart audits will be completed monthly to ensure medications and treatments are labeled appropriately. This Plan of Correction constitutes a written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. The overall operations of the facility are maintained within the State and Federal guidelines. The results of this survey reflect a small sample of residents within a small period of time. This Plan of Correction is submitted solely to meet requirements established by State and Federal law