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🔎 Carrington Place At Wytheville - Birdmont Center

Inspection Results


Inspection Overview

Carrington Place At Wytheville - Birdmont Center has been cited for a total of 56 deficiencies since we began saving each survey.

In Virginia, the average facility has **43.98 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Keep all essential equipment working safely.

Survey Date: 2024-02-02
Correction Date: 2024-03-13
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2022-05-12
Correction Date: 2022-05-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2022-05-12
Correction Date: 2022-05-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Perform COVID19 testing on residents and staff.

Survey Date: 2022-05-12
Correction Date: 2022-05-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-06-07
Correction Date: 2019-07-19
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2018-03-01
Correction Date: 2018-04-04
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**