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. 17, 2021 , Aug. 18, 2021 and Aug. 19, 2021

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 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:

Recommendations discussed with the administrator: 1) Putting the time frames of all activities that are more then 30 minutes in length due to the statement on the activities calendar that all activities are at least 30 minutes. 2) Contacting the fire official to clarify the requirements for conducting a fire drill.

Comments:

A renewal inspection was initiated on 8/17/2021 and concluded on 08/19/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 78. The inspector emailed the administrator a list of items required to compete the remote documentation review portion of the inspection. The inspector reviewed four resident and four staff records, selected sections of one resident and five staff records, activities calendar, menu, staff schedules, fire drills, health care oversight, dietary reviews, medication administration records, physicians' orders and other information submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 8/19/2021. An exit interview was conducted with the administrator on the date of the inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon documentation, observations and interviews, the facility failed to implement the medication management plan in order to ensure one treatment cream was available for one of four residents' records reviewed. EVIDENCE: 1. Resident 4 had a physician's order signed 8/9/2021 for triamcinolone acetonide cream to be applied to face with shaving on bath days for rash, once a day on Tuesdays and Fridays. 2. The August EMAR listed triamcinolone acetonide cream to be applied to face with shaving on bath days for rash, once a day on Tuesdays and Fridays (start date 8/1/2021). 3. The EMAR was circled for 8/10/2021 and the documentation was "Not administered: I don't see any cream available in the cart for him. Therefore, it was no given." .4. On 8/19/2021, the LI conducted an audit of the medication cart and the triamcinolone cream was not in the cart. The DON and the medication aide on duty also checked the cart and they could not find the cream. 5. The administrator, DON and medication aide were all interviewed and all stated the cream could not be found. 6. The medication management plan states on page 6, 8.b, "All medication staff are responsible for monitoring the need for refills."
Plan of Correction:	Medication was reordered the day of the inspection and was available for the next scheduled dose. Administrator or designee will review the medication management plan with all RMAs with emphasis on reordering medications. All RMAs will attend an in-service or complete a take home test on how and when to reorder medications and what steps to take if medication is not available at time of administration. During the in-service or take home test, staff will also be re-educated about where resident creams are to be stored in the cart so that all staff may be able to find them quickly. All RMAs will be required to complete this in-service by 9/25/2021. To prevent this from reoccurring, the RMA supervisor/resident care coordinator or designee will print a report weekly to check for medications that have been documented as not given and will follow up with those staff. Resident care coordinator or designee will ask staff on rounds each morning if there are medications that have not yet come from the pharmacy. If medication has not been received from the pharmacy in the specified time frame, administrator will be notified and will contact the pharmacy to ensure that the medication is available by the next administration.
Standard #:	22VAC40-73-680-E
Description:	Based upon documentation, the facility failed to ensure two of four residents received all treatments as ordered. EVIDENCE: 1. Resident 2 had a physician's order signed 8/17/2020 for blood sugar checks twice a day before breakfast and supper. 2. The EMAR was blank for the blood sugar check on 7/10/2021 at 4:00 pm. 3. Resident 4 had a physician's order signed 8/9/2021 for knee high TEDs on in the morning and off at night for edema. 4. The EMAR was blank on 8/11/2021 and 8/15/2021 at 8:00 pm.
Plan of Correction:	All RMAs will be required to attend an in-person review of documenting on the EMAR or an in-service by 9/25/2021. To help with prevention of documentation errors, RMAs will document medication within the specified time frame of five (5) minutes now set by the EMAR system. If RMA does not document within that time frame they will need to go in and restart the process for documenting administration. At the end of each medication pass, the RMA will check the EMAR filter located in the top left hand corner to ensure that no medications are due, late, stat, or to follow-up. If medications are still showing not given, RMA will follow-up to ensure that documentation has been charted. The dashboard of the EMAR has been updated with a widget that shows any overdue medication that needs to be administered. This information will be included in each RMAs dashboard daily. Upon shift change, oncoming/ongoing RMA will check the EMAR/Late Administrations tab located on their dashboard to ensure that all medications have been administered on their shift. If medications are noted as still need to be given, RMA will go back in and document appropriately at that time. Each week the RMA supervisor/resident care coordinator will print out a report which will show missed administrations to help with prevention of missed documentation in the future. If there are med administrations missed, the RMA responsible will be questioned and will need to correct the documentation appropriately.by completing a medication administration/documentation error form.
Standard #:	22VAC40-73-680-I
Description:	Based upon documentation and interviews, the facility failed to ensure all required documentation was included in the July and August electronic medication administration records (EMARs) for three of the four residents' records reviewed. EVIDENCE: 1. Resident 2 had physician's orders signed on 6/1/2021 for Basaglar KwikPen Insulin 50 units every day, magnesium 250mg every evening, metoprolol tartrate 12.5mg twice daily, rosuvastatin 20 mg at bedtime, senna two 8.5mg twice daily. 2. The EMARs for resident 2 was not initialed on the following days for all medications (insulin, magnesium, metoprolor tartrate, rosurvastatin and senna): 7/10/2021 at 8:00 pm and 8/15/2021 at 8:00 pm 3. On 8/19/2021, the licensing Inspector (LI) interviewed staff 9 who stated she had electronically signed the EMARs but did not know why the signature was not showing. She stated she has never failed to give any resident their medications since she has been employed. She also stated the system has had some glitches but was unaware the EMARs were showing as blank for these days. 4. Resident 3 had a physician's order signed 7/14/2021 for Chocolate Thrive Gelato one daily as needed; however, this order was not listed on the July or August EMARs. 5. Resident 4 had physician's orders signed 4/14/2021 for atorvastatin one 80mg tablet at bedtime, carbidopa/levodopa one 25-100mg tablet four times a day, latanoprost(one drop in each eye every nigh), metoprolol tartrate one 25mg tablet every 12 hours, and macrodantin one 50mg tablet at bedtime (signed by physician on 7/9/2021). 6. The EMARs for resident 4 was not initialed on the following days for all medications (atorvastatin, carbidopa/levodopa, latanoprost, macrodantin and metoprolol tartrate: 7/31/2021, 8/11/2021 and 8/15/2021 at 8:00 pm. 7. The EMAR for resident 4 was blank for carbidopa/levidopa on 8/9/2021 at 4:00 pm. 8. On 8/19/2021, the LI interviewed the administrator who stated they have been having issues with the EMAR system and have been implementing multiple changes. The administrator also stated the system times out staff after three minutes and 30 seconds. 9. On 8/19/2021, the LI interviewed the director of nursing (DON) who stated they have had issues with the new EMARs. She also stated the end of cycle medication cards had no medications left in them. She stated when there are medications left in the cards at the end of the cycle, the staff who changes out the cards gives them to her to check/review and she was not given any to check. 10. On 8/20/2021, the LI interviewed staff 11 who stated she was the one who changed out the medication cards during July/August and that there were no medications left on the cards. She also stated when there are medications left, she confirms there was a reason (such as at the hospital) and then leaves the cards that have medications still in them for the DON to review.
Plan of Correction:	All registered medication aides (RMAs) will be required to attend an in-person review of documenting on the EMAR or an in-service by 9/25/2021. To help with prevention of documentation errors, RMAs will document medication within the specified time frame of five (5) minutes now set by the EMAR system. If RMA does not document within that time frame they will need to go in and restart the process for documenting administration. At the end of each medication pass, the RMA will check the EMAR filter located in the top left hand corner to ensure that no medications are due, late, stat, or to follow-up. If medications are still showing not given, RMA will follow-up to ensure that documentation has been charted. The dashboard of the EMAR has been updated with a widget that shows any overdue medication that needs to be administered. This information will be included in each RMAs dashboard daily. Upon shift change, oncoming/ongoing RMA will check the EMAR/Late Administrations tab located on their dashboard to ensure that all medications have been administered on their shift. If medications are noted as still need to be given, RMA will go back in and document appropriately at that time. Each week the RMA supervisor/resident care coordinator will print out a report which will show missed administrations to help with prevention of missed documentation in the future. If there are med administrations missed, the RMA responsible will be questioned and will need to correct the documentation appropriately by completing a medication administration/documentation error form.