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. 17, 2024 , Jan. 18, 2024 and Jan. 22, 2024

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: 01/17/2024, 10:40am to 3:05pm, 01/18/2024, 10:00am to 3:47pm, 01/22/2024, 10:00am to 4:20pm 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 14 Number of staff records reviewed: 21 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 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 #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to obtain the results of the annual tuberculosis risk assessment for two of the five staff records reviewed. EVIDENCE: 1. Staff #2 started work on 07/25/2012; the most recent report of TB risk assessment observed in the record for staff #2 was dated 12/16/2022. 2. Staff #5 started work on 09/10/2015; the most recent report of TB risk assessment observed in the record for staff #5 was dated 12/16/2022.
Plan of Correction:	All current employees will have TB risk assessment completed, if indicated followed by PPD or CXR. This will be done annually. All new hires will receive TB assessment upon hire. If indicated a PPD or CXR will also be obtained. HR Director will audit and monitor for compliance. [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, and the individual resident and his or her legal representative, if any, for two of the resident records reviewed. EVIDENCE: 1. Resident #4 was admitted to the facility on 01/01/2022; there was no verification/acknowledgement of the required interview. 2. Resident #5 was admitted to the facility on 08/12/2022; there was no verification/acknowledgement of the required interview.
Plan of Correction:	All residents seeking admission to facility will have documented interview prior to acceptance. Assistant Administrator or Designee will complete interview. Any resident admitted prior to this date without interview sheet will have documentation in file saying such. Administrator/Asst. Admin will monitor for compliance. [SIC]
Standard #:	22VAC40-73-325-A
Description:	Based on a review of resident records, the facility failed to ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating shall be completed, for three of the resident records reviewed. EVIDENCE: 1. Resident #1 was admitted to the facility on 12/27/2023; there was no documentation of a written fall risk rating found in the record for resident #1. 2. Resident #2 was admitted to the facility on 12/22/2023; there was no documentation of a written fall risk rating found in the record for resident #2. 3. Resident #3 was admitted to the facility on 10/09/2023; there was no documentation of a written fall risk rating found in the record for resident #3.
Plan of Correction:	All residents will have fall risk rating completed. All resident charts will be audited by nursing. All new admissions shall have fall risk rating completed within 30 days post admission. Annually and with a significant change the risk rating will be updated and reevaluated. LPN will complete fall risk rating. Assistant Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility failed to ensure the fall risk rating shall be reviewed and updated at least annually for four of the resident records reviewed. EVIDENCE: 1. Resident #5 was admitted to the facility on 08/12/2022; there was no documentation of an annual review and update of the fall risk rating found in the record for resident #5. 2. Resident #6 was admitted to the facility on 01/23/2021; there was no documentation of an annual review and update of the fall risk rating found in the record for resident #6. 3. Resident #7 was admitted to the facility on 12/12/2019; there was no documentation of an annual review and update of the fall risk rating found in the record for resident #7. 4. Resident #8 was admitted to the facility on 04/05/2018; there was no documentation of an annual review and update of the fall risk rating found in the record for resident #6.
Plan of Correction:	Residents #5,#6, #7 and #8 will have new fall risk rating completed. All fall risk ratings will be reviewed and updated at least annually. LPN will complete fall risk rating. Assistant Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to ensure that prior to or at the time of admission, all required personal and social information on a person shall be obtained for two of the resident records reviewed. EVIDENCE: 1. Resident #4 was admitted to the facility on 01/01/2022; the resident personal/social data form was not found in the record for resident #4. 2. Resident #5 was admitted to the facility on 08/12/2022; the resident personal/social data form was not found in the record for resident #5.
Plan of Correction:	Resident #4, and #5 will have personal social data form completed. All resident files will be audited for personal social data forms, if needed staff will complete form to ensure each resident has one. All future admissions will have personal and social data form completed upon admission. Asst Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on the comprehensive individualized service plan (ISP) for three of the resident records that were reviewed. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident #4, dated 01/01/2024 identified the following areas in which the resident requires assistance: mobility (mechanical help only), meal prep and housekeeping. The comprehensive ISP for resident #4, dated 01/31/23, does not address these needs. Under ?Subsequent review/update of plan? on the last page, the ISP states ?Continue current plan through 01/31/24.? 2. The UAI for resident #5, dated 11/29/2023, identified the following areas in which the resident requires assistance: laundry and money management. The comprehensive ISP for resident #5, dated 11/29/2023, does not address these needs. 3. The UAI for resident #7, dated 12/22/2023, identified the following area in which the resident requires assistance: dressing (mechanical and human help, physical assistance), with the additional wording, ?assist with socks.? The comprehensive ISP for resident #7, dated 01/08/2024, does not address this need.
Plan of Correction:	Resident #4 ISP will be updated to address mobility, meal prep and housekeeping assistance needed. Resident # 5 ISP will be updated to address laundry,and money management assistance needed. Resident #7 ISP will be updated to address dressing assistance needed. All ISP?s will be completed based on the current UAI identified needs. LPN/Asst Administrator will complete ISP?s based on needs identified on UAI?s. Asst. Administrator/Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records, the facility failed to maintain written acknowledgement of annual review of rights and responsibilities of residents in assisted living facilities for two of the five staff records reviewed. EVIDENCE: 1. Staff #2 started work on 07/25/2012; the most recent acknowledgement of review of annual resident rights and responsibilities observed in record for staff #2 was dated 08/15/2020. 2. Staff #5 started work on 09/10/2015; the most recent acknowledgement of review of annual resident rights and responsibilities observed in the record for staff #5 was dated 01/13/2020.
Plan of Correction:	All current staff will review resident rights and responsibilities and sign acknowledgement. HR will audit and ensure review is completed annually with all staff. Assistant Admin/Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-620-A
Description:	Based on observations made during facility records review and interview with staff, the facility failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet. EVIDENCE: 1. Per staff #24, there were no records available at the facility documenting oversight of special diets by a dietitian or nutritionist within the past six months.
Plan of Correction:	Dietician was at facility and reviewed all residents on special diets on 1/31/24 -2/01/24. Recommendations will be communicated with MD for appropriate changes/additions. Assistant Admin/Admin will monitor to ensure oversight is completed every six months. [SIC]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit, the facility failed to implement its medication management plan including methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. EVIDENCE: 1. Per the physician orders as of January 2024 and January 2024 Medication Administration Record (MAR), resident #11 has an order for Miralax powder, take 17 grams mixed with 6-8 oz of liquid by mouth daily for constipation, dated 09/22/2023. During the medication cart audit on 01/17/2024, this medication was not found in the medication cart. Per staff #1, the medication had been ordered. On the final day of inspection, 01/22/2024, the medication was still not available. Per staff #1, it had not yet been delivered to the facility. 2. Per the physician orders as of January 2024 and January 2024 Medication Administration Record (MAR), resident #12 has an order for Miralax powder, take 17 grams mixed with 6-8 oz of beverage by mouth daily for constipation, dated 09/25/2023. During the medication cart audit on 01/17/2024, this medication was not found in the medication cart. Per staff #1, the medication had been ordered. On the final day of inspection, 01/22/2024, the medication was still not available. Per staff #1, it had not yet been delivered to the facility.
Plan of Correction:	Resident #11,and #12 have received refill of Miralax powder for dispensing on 1/22/24 at 6 p.m. Staff will be educated on proper procedure to follow if refilled medication is not received by pharmacy after reordering. LPN will audit carts weekly to ensure all medications are available. Asst. Admin/Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-680-D
Description:	Based on resident records review and observations made during the medication pass and medication cart audit, the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber?s instructions. EVIDENCE: 1. Per the physician orders as of January 2024 and the January 2024 Medication Administration Record (MAR), resident #12 has three separate orders for alprazolam, dated 01/02/2024; the orders are written as follows: a. Alprazolam 0.5mg tablet: oral once an afternoon daily. 1 tablet by mouth daily at 1:00pm for anxiety. b. Alprazolam 0.25mg tablet: by mouth AM med pass time daily. 1 tablet by mouth daily in the AM for anxiety. c. Alprazolam 0.5mg tablet: oral bedtime med pass daily. 1 tablet my mouth at bedtime for anxiety. During the medication cart audit, the only alprazolam found in the cart for resident #12 was the 0.5mg dosage tablets. Per staff #1, only the 0.5mg dosage of alprazolam was being administered to resident #12 for all three orders noted above, including the order for the 0.25mg tablet. 2. Per the physician orders as of January 2024 and the January 2024 MAR, resident #11 has an order for acetaminophen 325 tablet: Administer 2 tablet(s) by mouth (650mg total dose) every 6 hours as needed PRN (as needed). The instructions on the medication label state: Acetaminophen 325mg tablet, Take 2 tablets (650mg) by mouth every 12 hours as needed for leg pain.
Plan of Correction:	Resident #12 orders for Alprazolam have been clarified with physicians? current orders. Medication Administration Record was updated, medication card was flagged with instructions to review MAR for current dispensing instructions, and pharmacy notified. Resident #11, Tylenol order has been clarified with Physician. Medication Record updated with new orders, medication card flagged with instructions to review MAR for current dispensing instructions and pharmacy notified. Staff will be in serviced on proper administration of medications by physician orders. Staff also will be in serviced on proper procedure for flagging medication cards for any orders that may change after medication is received. LPN will review physician orders monthly. Asst. Admin/Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-700-1
Description:	Based on a review of resident records, the facility failed to ensure the physician's or other prescriber's order included all necessary components for two residents. EVIDENCE: 1. The physician?s orders as of January 2024 for resident #10 include an order for oxygen, dated 01/16/2024. The order states the following: O2 at 2lpm via nasal cannula for COPD. The order did not include the oxygen source, such as compressed gas or concentrator. 2. The physician orders list for resident #7 includes an order for oxygen, dated 02/03/2023. The order states the following: Oxygen at 3L/NC continuously. The order did not include the oxygen source, such as compressed gas or concentrator.
Plan of Correction:	Resident #7 and #10 orders have been modified by physician with name, route, and source. All physician orders will include all necessary components to complete order. LPN will audit physician orders. Asst Admin/Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure each bedroom contains all required items. EVIDENCE: 1. There were no operable bed lamps or bedside lights observed in resident rooms #374 and #274. 2. There are two residents assigned to rooms #362 and #271; there was only one operable beside light observed in each of these rooms. 3. There were no sturdy chairs observed in resident rooms #372 and #362. 4. There are two residents assigned to room #271; there was only one sturdy chair observed in this room.
Plan of Correction:	All resident rooms will be audited to ensure all have required items. If resident declines item, a signed acknowledgement will be on file in resident record. Residents in room 374, 274, 362,271,372, 362, and 271 will be spoken to and items will be supplied or declination on file. Maintenance will ensure all rooms are set up with required items for future admissions. Asst. Admin/Administrator will monitor for compliance. [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 resident room #318, the hot water at the bathroom sink reached a temperature of only 98.6 degrees Fahrenheit. 2. In resident room #319, the hot water at the bathroom sink reached a temperature of only 103.1 degrees Fahrenheit.
Plan of Correction:	Maintenance staff will monitor hot water tap temperature in Rm 318, and 319 daily and include random other rooms on unit daily for 30 days to ensure hot water temp is between range of 105-120 degrees Fahrenheit. Asst. Admin./Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. There were multiple dark stains observed on the carpet by the bed closest to the bathroom in resident room #371. 2. There were multiple dark stains observed on the carpet throughout resident room #372. There were also particles of dirt and debris by the bed closest to the door and to the right of the bedside table by the same bed. 3. There were dark stains on the carpet in resident room #370, by the dark brown recliner, in front of the chest of drawers by the mini fridge, and in front of the door to the bathroom. In the same room, the paint on the bottom portion of the wall between the shower and bathroom sink was bubbled and peeling with a dark stain just above the baseboard. 4. There were dark stains on the carpet in resident room #353, in front of the door to the hallway, and in front of the bedside table.
Plan of Correction:	Room #371, 372, 370, and 353 carpet will be shampooed by housekeeping staff. Room 370, maintenance will assess need for repair in the bathroom and repair and paint area. All resident rooms will be evaluated for need of carpet cleaning and repair and paint of walls. Housekeeping, Maintenance will audit monthly for needs. Asst. Admin/Administrator will monitor for compliance. [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: 1. There was a brown substance appearing to be feces on the outer portion of the toilet bowl in resident room #371. 2. There were dark spots observed on the surface of the toilet bowl in resident room #362. 3. There were several small dark spots and a large dark stain on the surface of the toilet bowl in resident room #274. 4. The shower door in resident room #259 did not operate correctly as it could not be closed completely and therefore did not latch.
Plan of Correction:	Rooms # 274, #362, and 371 toilets was cleaned by housekeeping. Room #259, maintenance will repair the shower door in room to ensure closes properly. Housekeeping and maintenance will audit rooms monthly. Asst. Admin/Adminstrator will monitor for compliance. [SIC]
Standard #:	22VAC40-90-40-B
Description:	Based on a review of resident records, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The date of hire (DOH) for staff #10 was 06/22/2023; the criminal history record report was requested on 08/14/2023. 2. The DOH for staff #11 was 07/11/2023; the criminal history record report was requested on 01/17/2024. 3. The DOH for staff #12 was 07/27/2023; the criminal history record report was requested on 01/17/2024. 4. The DOH for staff #13 was 07/27/2023; the criminal history record report was requested on 01/17/2024.
Plan of Correction:	All current employee files will be audited by HR Director to ensure criminal history records are obtained and approved. All new hires will receive criminal background verification prior to employment being offered by HR Director. [SIC] Asst. Admin/Administrator will monitor for compliance.