VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shenandoah Place, Inc.
50 Burkholder Lane
New market, VA 22844
(540) 740-4300

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: April 17, 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 EMERGENCY PREPAREDNESS 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

Technical Assistance:

Discussion occurred on the following topics: 1) Ensure parameters are included on orders for blood glucose monitoring. 2) Ensure all mechanical supports are identified on residents' ISP.

Comments:

An unannounced monitoring inspection was completed on 04/19/2019 from approximately 9:15am until 3:15pm. There were 20 residents in care. The facility was clean and free from any foul odors. The activities calendar and menu accurately reflected what the LI observed. Licenses and certifications were reviewed. The April medication administration records were reviewed for a select number of residents. Seven resident, one discharge and five staff records were reviewed. There were two violations during this monitoring inspection relating to practice of resident emergencies and review of emergency preparedness and response plan. Details of non-compliance can be viewed in the violation notice section of this report. If you have any questions, contact your licensing inspector at (540)332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-950-C
Description:	Based on documentation and an interview, the facility failed to ensure that at least every six months, all staff on each shift, residents, and volunteers participate in a review on the emergency preparedness and response plan. The review shall be documented by signing and dating. EVIDENCE: 1) Documentation on file indicates the most recent review of the emergency preparedness and response plan was completed on 03/20/2018. 2) The LI interviewed the new administrator who stated there were no other records on file indicating a review had been completed since 03/20/2018.
Plan of Correction:	A review of the emergency preparedness and response plan will be completed with all staff, residents and volunteers every six months; a review will be held immediately with appropriate documentation per regulations. The facility administrator will continue to schedule the review every six months and will monitor all staff, resident and volunteer attendance to ensure compliance.
Standard #:	22VAC40-73-990-C
Description:	Based on documentation and an interview, the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. EVIDENCE: 1) Documentation on file indicates the most recent review was completed on 03/20/2018. 2) The LI interviewed the new administrator who stated there were no other records on file indicating a review had been completed since 03/20/2018.
Plan of Correction:	Emergency drills will be performed every six months; an exercise on resident emergencies will be held immediately with appropriate documentation per regulations. The facility administrator will continue to schedule an exercise every six months and will monitor all staff attendance to ensure compliance.