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. 15, 2022 , Aug. 16, 2022 and Aug. 17, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 663.2 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 3.2 GENERAL PROVISIONS

Technical Assistance:

Topics discussed with the assisted living facility administrator and the management team: 1. Now that the facility is transitioning from paperwork to electronic documents, ensure all documents that require a signature are still signed either electronically or by an actual wet signature (such as sworn statements, residents? rights, etc.). 2. Obtaining a non-toxic dish liquid so residents may wash their own dishes when using the kitchen area on each unit. 3. When starting to replace windows, ensure the locking devices that prevent windows in the common and bedroom areas from opening enough for a resident to crawl through are reinstalled on the windows in all rooms/units where cognitively impaired residents reside. 4. Providing the medication administration record instead of the medication list when sending out a resident by rescue squad. 5. Reviewed, discussed and answered questions on the healthcare oversight process and explained full reviews are required at least annually on every resident (facility currently does monthly reviews on selected sections of residents? records). 6. Conducting in-services along with the fire drills. 7. Only required to post all direct care/nursing staff who are certified in first aid/cardiopulmonary resuscitation ? are not required to post other staff certifications or their expiration dates.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/15/2022 from approximately 8:45 am to 5:40 pm, 5/16/2022 from approximately 8:15 am to 5:45 pm and 8/17/2022 from approximately 9:00 am to 4:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 + selected sections of 3 additional records Number of staff records reviewed: 5 + 2 volunteer records + 6 private sitter records and selected sections of 2 additional staff records Number of interviews conducted with residents: 7 Number of interviews conducted with staff: 7 Observations by licensing inspector: Medication administration observations, medication cart checks, meals/special diets, activities and staff/resident interactions. Additional Comments/Discussion: The facility is transitioning from paper documents to online documents, thus, more time was required to collect the required information to complete the inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector, at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based upon record reviews and interviews, the facility failed to ensure six of the six private sitter records reviewed had documentation of orientation completion conducted by the facility. Evidence: 1. Collateral 3, 4, 5, 6, 7 and 8 had no documentation on file of orientation completion or training by the facility. 2. On 8/17/2022, the licensing inspector (LI) interviewed staff 8 and 10 and both stated the facility staff had not conducted an orientation with the private sitters but the facility provided the information to the agency and they conducted the orientation with them.
Plan of Correction:	Current private duty caregivers will have an updated orientation completed by social services manager or administrator and placed on file. Moving forward, all private care giving staff will have an orientation completed by the facility their first day of assignment. Administrator, social services manager, nurse, or registered medication aide (RMA) will review the information with the private care giving staff and sign before staff begins to provide care for resident. Facility staff will make a copy and put it in the private care givers binder. Facility staff will give other copy to the social services manager. Administrator or designee will ensure that all private duty caregiving staff have orientation completed and on file prior to providing any services.
Standard #:	22VAC40-73-620-B
Description:	Based upon documentation and interview, the facility failed to ensure all of the requirements of the dietary oversight were in writing and included certification that all of the requirements in this standard were met. Evidence: 1. The dietary oversight completed on 8/22/2022 for residents 12 and 13 did not include certification that the physicians? orders, preparation and delivery of the diet, evaluation of the adequacy of the diet and resident?s acceptance of the diet were reviewed. The oversight only included weight concerns, intake and recommendations. 2. On 8/17/2022, the LI interviewed the administrator who stated the dietician who normally completes the oversight has been on leave and a second dietician completed the most recent review and did not include all of the required information.
Plan of Correction:	Administrator has reviewed the regulation with the dieticians. On site dietary staff will add certification that the physicians? orders, preparation and delivery of the diet, evaluation of the adequacy of the diet, the resident?s acceptance of the diet have been reviewed to their oversight sheet. Administrator will ensure that this is listed on the dietician reports when received.
Standard #:	22VAC40-73-680-M
Description:	Based upon observations, documentation and interview, the facility failed to ensure one as- needed (PRN) medication for two of four residents reviewed were on-site and available. Evidence: 1. Resident 8 had a physician?s order (signed 7/7/2022) for sodium phosphates enema use one rectally every day as needed for severe constipation. 2. The July and August medication administration records (MARs) listed enema disposable use rectally every day as needed for severe constipation. 3. Resident 12 had a physician?s order (signed 7/12/2022) for one Bisacodyl tablet orally every day as needed for moderate constipation. 4. The July and August MARs listed one Bisacodyl orally every day as needed for moderate constipation. 5. On 8/16/2022, the LI conducted a medication cart audit with staff 4 on the Dogwood unit and the sodium phosphate enema for resident 8 and Bisacodyl for resident 12 were not in the medication cart. 6. On 8/16/2022, the LI interviewed staff 4 who stated these medications were not in the cart and were not available at the facility.
Plan of Correction:	On the day of the inspection, RMA ordered the enema and the Bisacodyl for the residents that were missing medication. Pharmacy delivered medication within 1 hour. RMA will review all PRNs for expiration and will ensure all medications that are ordered are in the med cart monthly per the medication cart. Administrator, resident care coordinator, RMA supervisor, or RMA preceptor will randomly audit carts each quarter to ensure all PRN meds are in the medication cart. Nurse from contracted pharmacy will also audit carts every 6 months. First quarterly oversight will be completed by 9/15/2022.