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. 5, 2020 and Aug. 6, 2020

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 63.2 General Provisions. 63.2 Protection of adults and reporting. 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

Technical Assistance:

1) Have a second person review the physical forms prior to filing to ensure all information is completed. Recommended putting "unknown" or "not applicable" rather than leaving information blank. Also recommend using the model form. 2) Ensure staff A (hired 12/16/19) and D (hired 7/6/20) complete the required mental health training hours each year. 3) Ensure staff on all units take the medication cart with them when administering medications to avoid being timed out for the second sign off. 4) Recommended adding a statement at the bottom of each activities calendar that indicates the minimum length of each activity, if space does not allow including the length of every individual activity. 5) Need to add a statement on the staff schedule which indicates the asterisk (*) represents the staff in charge. 6) Even though the dietitian and pharmacy completed individual reports for each resident, as well as a summary, ensure a statement is included in each summary report that states the requirements of the standards were met (620.B.3 and 690.F).

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 7/30/20 and concluded on 7/31/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 86. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident and five staff records. A virtual tour was conducted as well as a review of the posted menu, activities calendar, facility license and violation notice. The staff schedule, resident council meeting minutes, July and August 2020 medication administration records, physicians' orders, call bell rounds, fire drills, pet immunizations, staff training and private duty aide information were also reviewed. The previous violations were checked, except for the first aid kit (due to connectivity issues with face time). Information gathered during the inspection determined non-compliance with standards 50.A, 660.B and 680.D.and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based upon documentation and an interview, the facility failed to ensure the most current disclosure from developed by the department was being used. Evidence: 1) The disclosure forms for residents B (admitted 7/30/20), C (admitted 10/22/19) and E (admitted 3/3/20) were dated 2/19; however, the most current form is dated 10/19. 2) On 8/6/20, the LI interviewed the administrator who stated they had not been using the most current model form.
Plan of Correction:	The disclosure statement has been updated to reflect the most recent standard. All old disclosure statements have been removed and the new form will be used from here forward. Administrator will ensure that when there are updates from licensing that those are put into effect by the correct date.
Standard #:	22VAC40-73-660-B
Description:	Based upon documentation and an interview, the facility failed to ensure one of two resident records reviewed, who kept medications in their room, were assessed as capable of self-administering. Evidence: 1) Resident D was self-administering some of his over-the-counter medications and was storing them in his room; however, the uniform assessment instrument (UAI) indicated his medications needed to be administered by a lay person. 2) On 8/6/20, the LI interviewed the administrator who stated the UAI did not indicate the resident was capable of self-administering.
Plan of Correction:	Resident is a recipient of the auxiliary grant and the updated UAI was completed by the family services specialist (FSS) at the Department of Social Services (DSS). On 8/7/20, the social services manager (SSM) emailed the FSS and asked her to update the UAI to reflect that resident D self-administers medications. The FSS emailed back and has updated the UAI to reflect that resident is able to self-administer and is mailing an updated copy to the facility. The SSM will check all UAIs completed by the DSS.representative to ensure that the UAI is correct. IF they are incorrect, the FSS will contact the social services representative to correct them.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and an interview, the facility failed to ensure one of five residents' medications were administered according to the physicians' orders. Evidence: 1) The July medication administration record (MAR) for resident A was blank on 7/5/20 for the 8:00 pm medications (carbidopa/levodopa, lithium carbonate, lorazepam and quetiapine) and 9:00 pm medications (acetaminophen and melatonin). 2) On 8/6/20, the LI interviewed the administrator who stated she had questioned the staff; however, the staff could not remember if the medications were given or not.
Plan of Correction:	The staff member has been counseled on the importance of if it is not documented then it is not done. Physician and hospice have been notified about the possibility of the medication being missed. The current setting on the electronic medication administration records (eMARs) is to remind staff that documentation has not been completed for four hours after the medication is due. This reminder has been set to eight hours. All staff will be reminded to check to make sure that there is no outstanding documentation at shift change. Administrator or resident care coordinator will also run an eMAR report randomly each month to check for missed documentation..