VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Crestwood Assisted Living
1401 Virginia Avenue
Harrisonburg, VA 22802
(540) 564-3550

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Aug. 26, 2019 and Aug. 27, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Questions answered and recommendations given on the following: 1) Carefully review all paperwork prior to filing to ensure all information is accurate and complete. Do not draw lines through the orientation form as the trainer needs to sign and initial each section. 2) Recommended the sentence requesting allergies and allergic reactions be broken into two separate sections to avoid physicians overlooking the reactions (only one initial physical did not include this information). 3) Recommended updating the letter with one home care agency as was last completed in 2011. 4) Recommended adding a new column to the fire drill model form for "actions taken to correct problems." This information was documented on the facility fire drill form, as was all required information; however, the model form did not. 5) Ensure the violation notice remains on the top of the table at the entrance and not on the bottom shelf. 6) Even though the emergency preparedness training is completed on Relias, ensure staff and volunteers, as well as residents, still sign and date that they completed the training. 7) The food consumption log had a few blanks, ensure staff note "out of building" instead of leaving a blank.

Comments:

An unannounced renewal inspection was conducted on 8/26/19 from approximately 8:20 am to 6:45 pm with two inspectors and on 8/27/19 from approximately 7:20 am to 5:30 pm with one inspector. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors. There were 79 residents in care and eight direct care staff on duty. The breakfast and lunch meals were observed. The posted menu and activities calendar accurately reflected the inspectors' observations. The special diets observed were served according to the physicians' orders. Medication administration observations were completed for two residents. The August 2019 medication administration records (MARs), medications and orders were reviewed for these two residents as well as the MARs were reviewed for all 79 residents. Criminal record checks were reviewed for all current staff hired and new board officers since the last inspection. Individual interviews were conducted with residents, family members and staff. Eleven resident, one discharge, two volunteer and five staff records were reviewed. Selected sections of two additional resident and staff records were also reviewed. The areas of noncompliance included medication administration documentation, first aid kits, menus and staff training. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-200-D
Description:	Based upon documentation and an interview, the facility failed to ensure one of six staff had a copy of their qualifications on file. Evidence: 1) Staff G (hired 2/18/19 as a direct care and registered medication aide) did not have a copy of completion of any direct care training on file. 2) On 8/27/19, the LI interviewed the human resource staff and the administrator and neither had a copy of staff G's direct care training.
Plan of Correction:	The staff member's direct care aide certification is now in her chart. When a RMA is hired for a position, the human resources specialist (HRS) will review qualifications of the individual. The HRS will check the board of nursing for validity of licensure. If the individual is a RMA but not a certified nursing assistant, the HRS will request a copy of the certificate of completion of an approved department of social services (DSS) course to be direct care aide (DCA). The qualifications will have to be reviewed prior to the employee working on the floor. The HRS has added the DCA certification to her checklist to prevent not having a copy of qualifications on file.
Standard #:	22VAC40-73-260-A
Description:	Based upon documentation and an interview, the facility failed to ensure one of six staff had current first aid (FA) certification. Evidence: 1) Staff F (hired 6/17/19) had no certificate of completion of FA training. 2) On 8/27/19, the LI interviewed the human resource staff and administrator and neither had verification of staff F's training. The administrator stated staff F had not completed the training but was scheduled to attend in September.
Plan of Correction:	First aid (FA) and cardiopulmonary resuscitation (CPR) training will be available to all staff within the first 60 days of hire. Staff who do not complete the training within the first 60 days will be removed from the schedule until training can be completed. During new hire orientation in Crestwood, administrator and scheduler will check CPR and FA qualifications. Administrator and scheduler will confirm that CPR/FA cards are in compliance with the DSS licensing standards upon first day of work on the floor with residents and will schedule required training that day. Scheduler will make sure the training is completed within the 60 days and if staff member is not in compliance then scheduler will notify administrator and staff member will be removed from the schedule until training is complete.
Standard #:	22VAC40-73-610-B
Description:	Based upon documentation, observations and an interview, the facility failed to ensure snacks were listed on the posted menu. Evidence: 1) On 8/26/19, the LI observed the posted menu for the week of 8/25 through 8/31 and snacks were not listed. 2) On 8/26/19, the LI interviewed the administrator and dining services director and both stated the snacks were not included on the posted menu.
Plan of Correction:	Dining services manager added the snack list on the weekly posted menu. Dining services manager (DSM) will ensure that snacks are printed on the weekly menu each week. Administrator will also check the weekly posted menus to ensure that snacks are listed and will report back to DSM if they are not on the menu.
Standard #:	22VAC40-73-680-I
Description:	Based upon documentation, the facility failed to ensure 17 of the 79 medication administration records (MARs) reviewed included all of the required documentation. Evidence: 1) The August 2019 MARs for residents A, R, O, S, T, U, V, W, Z, AA, E, CC, GG,II, JJ and KK did not consistently include the following when medications were administered: staff initials (including as-needed medications on the front when the back was completed), results of effectiveness and no start date for TED Hose for resident CC. 2) On 8/26/19, the LI interviewed the administrator and resident care supervisor (RCS) who both stated they were aware of the issues and have already addressed them with the staff.
Plan of Correction:	The eight records that were reviewed by licensing will be pulled by administrator and resident care coordinator (RCC). Staff who missed documentation will be counseled on the importance of following through with documentation. Registered medication aides (RMAs) will check the MAR at shift change to ensure all documentation is correct. Each week a supervisor will pull the MAR from one of the six neighborhoods to audit for compliance with documentation. If MAR does not have complete documentation then staff members who had incomplete documentation will be counseled. All medication aides will be in-serviced annually on importance of MAR documentation and consequences of not documenting.
Standard #:	22VAC40-73-980-A
Description:	Based upon observations, the facility failed to ensure two of the three first aid kits checked (one was the van first aid kit and two were in the facility) included all required items. Evidence: 1) The flashlight in the first aid kit on Redbud did not have working batteries; 2) The first aid kit on Dogwood did not have a flashlight, cold pack, triangular bandage or antiseptic wipes or ointment.
Plan of Correction:	On the day of inspection, the batteries not working in the Redbud flashlight were replaced immediately with the extra batteries in the first aid kit. New working batteries were put back into the first aid kit to replace those that were used. The flashlight, cold pack, triangular bandage and antiseptic ointment were also replaced immediately into the first aid kit on the Dogwood neighborhood. The first aid kit will be checked monthly by the direct care staff. One time per month the night shift supervisor will randomly check one of six first aid kits to ensure compliance.