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: May 6, 2024

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: 5/6/2024 09:00 to 11:45am 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 4/30/2024 regarding allegations in the area(s) of: Administration and Administrative Services, Personnel, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services and Resident Care and Related Services A violation notice was 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure reporting 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 any resident. EVIDENCE: 1. The record for resident 1 contained an incident report dated 3/14/2024 with documentation that the resident was observed on the floor, screaming in pain. The resident had an unwitnessed fall. The resident was observed with blood coming out of their mouth and had a bruised right eye area. Resident was taken to hospital. 2. The record for resident 1 contained a charting note dated 3/15/2024 that has documentation that the resident returned to the facility from the ER due to a fall today on 7a -7p shift. The resident had significant bruising to the right eye and the eye was swollen closed. The POA stated the resident had lost a tooth and was unable to get sutures in the 2 open cuts on the resident?s top lip. The resident has swelling on lips and mouth area. 3. On the day of inspection during an interview with licensing inspector and staff person 6, staff person 6 confirmed that the facility did not report the incident to the regional licensing office.
Plan of Correction:	Department of Social Services Inspector provided education to Administrator on indicators of reportable incidents. Administrator and Resident Care Director will review all incident reports and charting notes daily and will determine if any incident is non-reportable or reportable based on education provided by Department of Social Services inspector. Administrator will review all incidents with Campus Executive Director regularly and appropriately report indicated incidents to Department of Social Services.
Standard #:	22VAC40-73-680-K
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure the use of PRN medications are only used when the resident is capable of determining when the medication is needed, or Medication aides administer the PRN medication when the facility has obtained from the resident's physician or other prescriber a detailed medication order. EVIDENCE: 1. The record for resident 1, who resides in a safe, secure unit with a serious cognitive impairment, has a physician?s order dated 9/1/2023 for a PRN medication Lorazepam 0.5mg tablet, take one tablet by mouth twice daily as needed (Control). The order does not contain symptoms that indicate the use of the medication and directions as to what to do if symptoms persist. 2. The March 2024 Medication Administration Record (MAR) in the record for resident 1 has documentation that the resident was administered this medication by staff person 1 on 4/2, 4/13, 4/15, 4/17, staff person 2 on 4/7, staff person 3 on 4/11, staff person 4 on 4/19, 4/27, and staff person 5 on 4/28. The MAR has documentation that these staff persons are Registered Medication Aides.
Plan of Correction:	An audit of all PRN orders was completed by Resident Care Director with physician orders completed and any corrections made. An audit was completed of all medications orders to ensure proper instructions by administrator and campus executive director and will correct any adverse findings. An audit of all PRN orders will be completed by Resident Care Director and Administrator bi-weekly.