Deficiency Records for Carrington Place at Botetourt Commons
Updated as of March 01, 2024
A list of the most recent deficiencies for Carrington Place at Botetourt Commons. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-03 | 2023-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-03 | 2023-08-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-03 | 2023-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-03 | 2023-06-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-03 | 2023-04-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-03-03 | 2023-04-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-03 | 2023-04-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-03 | 2023-04-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-03 | 2023-04-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-16 | 2023-04-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-16 | 2023-04-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-16 | 2023-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-04-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-16 | 2023-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-04-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-16 | 2023-04-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-16 | 2023-04-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-16 | 2023-04-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-16 | 2023-04-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-16 | 2023-04-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-16 | 2023-04-05 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-16 | 2023-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-16 | 2023-04-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-16 | 2023-04-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-28 | 2021-07-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-27 | 2021-07-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-27 | 2021-07-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-27 | 2021-07-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-27 | 2021-07-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-27 | 2021-07-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-27 | 2021-07-11 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-05-27 | 2021-07-11 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-27 | 2021-07-11 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-27 | 2021-07-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-19 | 2019-05-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-19 | 2019-05-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-04-19 | 2019-05-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-19 | 2019-05-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-04-11 | 2019-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-11 | 2019-05-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-04-11 | 2019-05-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-11 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-11 | 2019-05-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-11 | 2019-05-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-04-11 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-11 | 2019-05-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-11 | 2019-05-17 | N |
