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: June 4, 2024 and June 13, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/4/2024 10:45am to 11:30am 6/13/2024 09:30am to 11:35am 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 5/13/2024 regarding allegations in the areas of: Resident Care and Related Services Staffing and Supervision Buildings and Grounds Additional requirements for facilities that care for adults with serious cognitive impairments 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: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 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: Resident Care and Related Services Additional requirements for facilities that care for adults with serious cognitive impairments. A violation notice was issued; any violation(s) not related to the complaints 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 276.623.6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1020-A
Complaint related:	Yes
Description:	Based on facility records, resident records, building observation and staff interview, the facility failed to ensure there are at least two direct care staff members awake and on duty at all times in each building who are responsible for the care and supervision of the residents. EVIDENCE: 1. Resident 1 record has a Report of Resident Physical Examination dated 5/13/2024 that has documentation for diagnosis of Alzheimer?s dementia and intellectual disability and that this person is non ambulatory (by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person). Resident 1 record has a Uniform Assessment Instrument (UAI) dated 4/16/2024 that has documentation that the resident is disoriented to time and place, some of the time. The resident resides on the Assisted Living Unit, Daleville. 2. Resident 2 record has a Report of Resident Physical Examination dated 5/8/2024 that has documentation for diagnosis of Alzheimer?s dementia with mood disturbance and that this person is non ambulatory (by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person). Resident 2 record has a UAI dated 5/2/2024 that has documentation that the resident is disoriented to time, some of the time. The resident resides on the Assisted Living Unit, Daleville. 3. Resident 3, admission date 4/28/2023, record has a Report of Resident Physical Examination dated 5/17/2023 that has documentation for diagnosis of Alzheimer?s disease and that this person is non ambulatory (by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person). The resident resides on the Assisted Living Unit, Daleville. 5. The assisted living unit, Daleville, has a mixed population consisting of residents who have serious cognitive impairments due to a primary psychiatric diagnosis of dementia or due to any other diagnosis who are unable to recognize danger or protect their own safety and welfare. The Daleville and Troutville Units are independent of each other as Daleville serves a mixed population and Troutville residents require a safe, secure environment. 6.The Daily Shift Assignment forms for May 2024 for Daleville Assisted Living Unit and Troutville Safe, Secure Unit both on the 1st Floor has documentation for the 7pm to 7am shift for dates 5/2, 5/4, 5/6 through 5/13, and 5/15 with 2 direct care staff on duty. 7. During an interview with the licensing inspector and staff person 1 on 6/11/2024, staff person 1 disclosed that no staff would be constantly on duty for the assisted living unit, Daleville, however 1 staff would periodically go to this unit to provide supervision and care. 8. On 6/13/2024 during an on-site inspection, the licensing inspector observed 1 staff on the Assisted Living Unit, Daleville. 9. On 6/13/2024, during an on-site inspection, an interview with the licensing inspector and staff person 2, staff person 2 confirmed they were the only staff providing care on the Assisted Living Unit, Daleville.
Plan of Correction:	Immediately adjusted staffing levels to meet 22VAC40-73-(10)-1020-A. Education provided to Administrator and Resident Care Coordinator regarding state mandated staffing for special care units. Education provided to Administrator and Resident Care Coordinator regarding difference between regular assistant living resident qualifications and special care unit resident qualifications. Daily census review is completed by Administrator and Resident Care Coordinator to ensure staffing numbers are compliant with state mandated staffing numbers. Audit conducted every shift by Resident Care Coordinator to ensure State mandated staffing levels.
Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on facility records and staff interview, the facility failed to ensure, during night hours, two direct care staff members are awake and on duty at all times in each special care unit and are responsible for the care and supervision of the residents when 22 or fewer residents are present. EVIDENCE: 1. The Daily Shift Assignment forms for May 2024 for Daleville Assisted Living Unit and Troutville Safe, Secure Unit both on the 1st Floor has documentation for the 7pm to 7am shift for dates 5/2, 5/4, 5/6 through 5/13, and 5/15 with 2 direct care staff on duty. 2. During an interview with the licensing inspector and staff person 1 on 6/11/2024, staff person 1 disclosed that the 2 staff on duty would be assigned on the safe, secure unit however 1 of these 2 staff would periodically go to the assisted living unit to provide supervision and care leaving 1 staff on the safe, secure unit.
Plan of Correction:	Immediately adjusted staffing levels to meet 22VAC40-73-(10)-1130 C. Education provided to Administrator and Resident Care Coordinator regarding state mandated staffing levels for memory care facilities. Daily census review completed by Administrator and Resident Care Coordinator to ensure staffing numbers are compliant with state mandated staffing numbers. Audit conducted every shift by Resident Care Coordinator to ensure state mandated staffing levels. Twice weekly meeting with Administrator and Resident Care Coordinator to review weekly schedules. Daily schedule meeting with Resident Care Coordinator and Campus Director of Nursing to review scheduling assignments.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on resident record review, staff interview, facility record review and observation, the facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. EVIDENCE: 1. Resident 2 record has a physician?s order dated 5/13/2024 with documentation for Aripiprazole 5mg Tablet take 1 tablet by mouth daily, Escitalopram 20mg Tablet take 1 tablet by mouth daily and Cyancobalamin (Vitamin B-12) 1000 mcg take 1 tablet by mouth daily. 2. Resident 2?s record has a June 2024 Medication Administration Record for the afore mentioned medications to be administered at 8am. 3. The Medication Management Plan has documentation that the ?Community's standard dosing schedule is at breakfast time, lunchtime, dinnertime, and bedtime.? 4. During an on-site inspection on 6/13/2024, the licensing inspector observed staff person 2 administer the 8 a.m. medication pass medications to resident 2 at 10:08am. Staff person 2 confirmed the medications were being administered late due to being the only staff person providing care for the residents on the unit. 5. During an interview on 6/14/2024 with the licensing inspector and staff person 1, staff person 1 disclosed that the facility?s breakfast time is at 8am.
Plan of Correction:	Immediately notified Physician and Resident Representative of medication being administered outside of time parameter. Education provided to agency employee regarding administering medications not earlier than one hour before scheduled administration time and not later than one hour after scheduled administration time. Medication administration competencies were completed on all licensed staff in which medication administration is within their scope including Carrington Cottages employees and agency employees. Daily audits completed by Resident Care Coordinator verifying medication administration accuracy.