VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Crystal Gardens Assisted Living, LLC
6712 Bostwick Drive
Springfield, VA 22151
(703) 642-5329

Current Inspector: Alexandra Roberts

Inspection Date: May 30, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES2VAC40-73 GENERAL PROVISIONS 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 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.

Comments:

An unannounced renewal inspection was conducted on 5/30/23. At the time of entrance, three residents were in care. Building and grounds were inspected and an activity were observed. Medications and records were reviewed. The sample size consisted of three resident records and three staff records. The violations were discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member submits the results of a tuberculosis risk assessment, on or within seven days prior to the first day of work at the facility, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: The record for Staff #3 (hired 10/20/22) was reviewed during the inspection. Staff #3's record included a tuberculosis risk assessment, dated 4/21/22. The tuberculosis risk assessment was more than 30 days old, when Staff #3 was hired.
Plan of Correction:	Steps made to correct non-compliance: Will make sure future staff applicants will comply with not more than 30 days PPD report requirement. Measure(s) to prevent the non-compliance from occurring again: We will make sure that PPD will be compiled, not more than 30 days upon employment. Person(s) responsible for implementing each step and or monitoring any preventative measures: Imelda Macadaeg, Manager
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #2's medications were reviewed during the inspection. Resident #2's medication administration record (MAR) indicated that his Losartan was held on 5/27/23 (BP: 94/47) and 5/29/23 (BP: 98/53), because his blood pressure was low. Resident #2's record did not contain parameters for the administration of his Losartan. Resident #2's MAR indicated that his Gabapentin was held on 5/27/23 (noon administration), because his blood pressure was too low. Resident #2's record did not contain any parameters for the administration of his Gabapentin.
Plan of Correction:	Steps made to correct non-compliance: Called the doctor's office regarding parameters for the concerned medications for administration, verbal order was received in advance for hold order, awaiting the signed doctor's order. Measure(s) to prevent the non-compliance from occurring again: Will make sure that parameters on such medications will be included in the Doctor's order. Person(s) responsible for implementing each step and/or monitoring any preventive measures: Judy Campanilla, RN
Standard #:	22VAC40-73-680-M
Description:	Based on documentation and interview, the facility failed to ensure that PRN medications are available and properly stored at the facility. Evidence: Resident #2's medications were reviewed during the inspection. Resident #2's PRN Acetaminophen, ordered 9/18/22, was expired at the time of the inspection. The medication package indicated that the Acetaminophen expired in March 2023. Facility staff confirmed that Resident #2 did not have any additional packages of PRN Acetaminophen at the facility. Resident #3's medications were reviewed during the inspection. Resident #3's PRN Bisacodyl was not present, at the time of the inspection. Resident #3 had a stool softener (Docusate Sodium 100mg) among this medications, but his PRN Bisacodyl 5mg (ordered 1/31/23) was not present. Facility staff confirmed that Resident #3's PRN Bisacodyl was not present.
Plan of Correction:	Steps made to correct non-compliance: Called family to supply these PRN medications. Measure(s) to prevent the non-compliance from occurring again: Medication aides in charge of medication administration should conduct inventory at least once a month for PRN medications. Person(s) responsible for implementing each step and/or monitoring any preventive measures: Imelda Macadaeg, RMA/Manager