Carrington Place of Tappahannock

In the surveyor’s words

From the most serious findings on record at Carrington Place of Tappahannock, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 1, 2023

  Based on Resident interview, staff interview, clinical record review and facility documentation review, the facility staff neglected to provide care and services for 1 Resident (Resident #4) in a survey sample of 10 Residents. This negligence resulted in mental anguish and emotional distress which constituted harm for Resident #4. The findings included: 1. For Resident #4 the facility staff neglected to obtain and provide his IV antibiotic medications upon admission, as agreed upon, which resulted in Resident #4 being in fear of his life. This resulted in mental anguish and emotional distress which constituted harm for Resident #4. On 5/30/23 at 12:13 PM, Resident #4 was visited in his room. […]

• Actual harm, isolatedF689Jun 1, 2023

  Based on Resident interviews, staff interviews, clinical record documentation and facility documentation review, the facility staff failed to provide adequate supervision, failed to implement fall precautions and failed to ensure a Resident received assistance in a manner to prevent accidents/injury for 1 Residents (Resident #1) in a survey sample of 10 Residents. Resident #1 sustained a fractured tibia this constituted harm for Resident #1. The findings included: 1. For Resident #1 the facility staff failed to ensure the Resident was assisted by facility staff in a manner to prevent injury, which resulted in a fractured tibia/resulting in harm. On 5/30/23 at 1:24 PM, an interview was conducted with Resident #1. […]

• No harm, potential for more than minimal, widespreadF680Jul 15, 2024

  Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could direct the provision of activities to the residents which resulted in substandard quality of care. The findings included: During the recertification survey conducted 7/9/2024 through 7/11/2024 and an extended survey conducted through 7/15/2024, residents were identified who could benefit from meaningful and individualized activity programs. […]

• No harm, potential for more than minimal, widespreadF880Jul 15, 2024

  Based on staff interview and facility documentation review, the facility staff failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with the potential to affect all residents in the facility. The Findings included: The facility staff failed to develop and implement a Legionnaire's water policy or program or Quality Assurance and Process Improvement (QAPI) program . During the entrance conference, the facility's Administrator stated the previous Maintenance Director had quit on 6/28/2024 and had not been replaced at the time of the survey on 7/9/2024. […]

• No harm, potential for more than minimal, widespreadF925Jul 20, 2023

  Based on observation, Resident and staff interviews, and facility documentation review, the facility staff failed to maintain an effective pest control program affecting 2 of 2 Resident care hallways. The findings included: The facility staff failed to ensure the Resident rooms and hallways were free of flies and gnats. On 7/18/23, during the survey entrance conference, the facility Administrator was asked to provide pest control logs. On 7/18/23 at 2:32 PM, Surveyors B and C made observations on both Resident care hallways. It was noted that in Resident rooms, flies and gnats were flying around Residents and were observed on the bed linen, of multiple Residents. On 7/18/23, the survey team was provided a document titled, weekly inspections for pest control. […]