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

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Feb. 25, 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
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) PRN oxygen orders are to include concentrator and portability.
2) UAI to indicate medication administration by lay person to include RMA.
3) Copy of additional 3 hours of medication administration refresher training for staff D to be sent to licensing office once completed.
4) Social data sheets to indicate N/A if not applicable and not to be left incomplete.

Comments:
A renewal inspection was conducted on 02/25/20 from approximately 8:45am until 4:15pm. There were 19 residents in care. The facility was clean and free from any foul odors. The activities calendar and lunch menu accurately reflected what the LI observed. Six resident, one discharge and four staff records were reviewed. January and February medication administration records were reviewed for a selected number of residents. There were twelve violations during this renewal inspection. Details of non-compliance can be viewed in the violation notice section of this report. If you have any questions, contact the licensing inspector at (540) 332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:
Standard #: 22VAC40-73-70-A
Description: Based upon documentation, the facility failed to ensure the regional licensing office is notified within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident.
EVIDENCE:
1) Incident report on file in the facility indicates resident L sustained a fall, hitting head on 02/07/20 at 5:55pm and was sent to the hospital.
2) Incident report on file in the facility indicates resident C was observed on floor on 02/23/20 at 7:50am, stated he had not felt well since 4:00am and requested for ambulance to be called.

Plan of Correction: Administrator submitted to the licensing office reports for the incidents stated in violation as of 2/27/20. In the future all incidents will be reported to the licensing office within 24 hours in accordance with regulations by the Administrator of Shenandoah Place.

Standard #: 22VAC40-73-70-C
Description: Based upon review of documentation, the facility failed to submit within seven days, a written report of a major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
EVIDENCE:
Incident report on file in the facility indicates resident L sustained a fall, hitting head on 02/07/20 at 5:55pm and was sent to the hospital.

Plan of Correction: Administrator submitted to the licensing office reports for the incidents stated in violation as of 2/27/20. In the future all incidents will be reported to the licensing office within 24 hours in accordance with regulations by the Administrator of Shenandoah Place.

Standard #: 22VAC40-73-320-A
Description: Based upon review of residents' records, the facility failed to ensure the physical examination report contained all required information.
EVIDENCE:
1) The physical exam for resident H does not include the date exam was completed.
2) The physical exam for resident I does not include the address and telephone number of the resident, date exam was completed and description of allergic reaction to Aricept.

Plan of Correction: The administrator of Shenandoah Place will assure that all required documentation is included in residents? charts and that all documents are complete at the time of each resident?s admission into the facility.

Standard #: 22VAC40-73-330-A
Description: Based upon review of residents' records and an interview, the facility failed to ensure a mental health screening was completed prior to admission.
EVIDENCE:
1) Resident H was in-patient at a behavioral health unit prior to admission on 09/06/19 and has a primary diagnosis of a mental illness.
2) The Uniform Assessment Instrument (UAI) for resident A indicates a psychological evaluation is needed.
3) There is no documentation of a mental health screening on file.
4) There is no paperwork on file relating to the discharge instructions for resident H from the behavioral unit indicating resident H's psychosocial and behavioral functioning.
5) The LI interviewed the administrator who stated that she was not aware a mental health screening had to be completed for resident H and that there was no discharge paperwork for resident H from the behavioral unit on file at the facility.

Plan of Correction: The administrator will assure that any resident requiring mental health screening will have that screening and the necessary paperwork will be completed prior to the individual?s admission into the facility. Follow up progress notes and contracts will be maintained as per regulation by the administrator..

Standard #: 22VAC40-73-450-C
Description: Based upon review of residents' records, the facility failed to ensure the assessed needs of the resident is included on the Individualized Service Plan (ISP).
EVIDENCE:
1) The UAI for resident H indicates supervision is needed with bathing. The ISP indicates resident is independent.
a. The UAI indicates mechanical assistance of handrails is needed with stair climbing. This is not reflected on the ISP.
b. The UAI indicates supervision is needed with bathing. The ISP indicates resident is independent but requires use of handrails.
2) The UAI for resident I indicates supervision is needed with dressing. This is not reflected on the ISP.
a. The UAI indicates no assistance is needed with bathing. The ISP indicates mechanical supports of handrails and bath bench is needed.
b. The UAI indicates resident is disoriented to some spheres some of the time. The ISP indicates resident is alert and oriented to all spheres.
c. Home health services is not indicated on the ISP.
3) The UAI for resident L indicates supervision is needed with bathing. The ISP indicates resident is totally dependent.
a. The UAI indicates supervision is needed with toileting and transferring. The ISP indicates physical assistance is needed.
b. The UAI indicates physical and mechanical assistance is needed with transferring. This is not reflected on the ISP.
c. The ISP does not include signature of the resident or the resident's legal representative.
d. The ISP does not include the date of completion.

Plan of Correction: The administrator will assure that documentation contained on the UAI and ISP will correspond accordingly and will address the resident?s specific plan of care. The UAI/ISPs will be reviewed yearly and as conditions change by the facility administrator or designated person with the appropriate training.

Standard #: 22VAC40-73-680-D
Description: Based upon review of residents' records, the facility failed to ensure 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:
1) Resident B has the following order effective 01/16/20: Thigh High Compression Stockings Medium Compression-Place on legs before patient gets out of bed and remove at bed time. Time on the MAR indicates 8:00am and 8:00pm
a. Documentation in the electronic Medication Administration Record (MAR) indicate resident has only worn the thigh high stockings prescribed from this order on 01/16/20, 01/17/20, 01/18/20 and 02/03/20.
b. Resident has another TED hose order effective 01/28/19 to apply at 8:00am and remove at 8:00pm. Documentation in the MAR indicates on 02/01/20 resident "refused to keep hose on", on 02/14/20 documentation indicates "resident refuses hose and new hose on resident" and on 02/20/20 resident refuses legs too swollen."
a. Documentation in the MAR relating to order effective 01/16/20 indicates on 02/14/20 at 12:20pm "resident refused."
b. There is no documentation of physician notification of legs being swollen, hose are too tight or that current order effective 01/16/20 is not being followed. /
c. There are duplicate orders effective 01/28/20 for TED Hose. Staff are documenting in the MAR on both orders.
d. Resident has an order effective 12/09/19 to apply Vasoline to surgical incision daily until area is healed. Documentation in the MAR indicates this w0as not applied on 01/01/20 through 01/10/20 and 01/12/20 through 01/19/20 as incision is healed. Documentation indicates it was applied on 01/11/20.
2) Resident C has the following order: Potassium DUR CL ER 20MEQ-Take two tablets by mouth every day.
a. Documentation in the MAR indicates only one pill was administered on 02/21/20 at 9:11am as "only 1 pill was left."
b. Resident has an order to check blood sugar three times a day prior to meals. Documentation in the MAR indicate resident refused 11 times from 02/02/20 through 02/23/20. There is no documentation of physician notification and Lantus and Humulin were still administered except on 02/18/20 at 12:00 and on 02/23/20 at 5:00pm.
3) Resident D has the following order: Ensure liquid chocolate-Take one can by mouth three times a day after meals for nutritional supplementation.
a. Documentation in the MAR indicates resident did not have Ensure on 02/11/20 at 8:00 "none here"; 02/22/20 at 2:00pm "resident out"; 02/22/20 at 8:00pm "resident does not have anymore in the fridge, let daughter know", 02/23/20 at 9:00 "resident refused"; 02/23/20 at 2:00pm "none here", 02/24/20 at 8:07am "resident refused", 02/24/20 at 2:00pm "resident does not have any in the facility, daughter aware."
4) Documentation in the MAR indicates resident D did not receive Oxycodone on 01/21/20 at 9:00am "daughter requested", 01/22/20 at 9:00am
held per daughter."; Potassium was not administered on 01/03/20 at 6:00pm "waiting on med to be delivered" and on 01/22/20 at 9:00am "held per daughter."; Daily weight was not obtained on 01/03/20 at 9:00am "resident still in bed", 01/21/20 "daughter request not taken" and on 01/23/20 "weight was not gotten from students in RMA class."; Amlodipine was not administered on 01/21/20 "daughter requested"; Carvedilol was not administered on 01/03/20 at 6:00pm "waiting on med to be delivered" and on 01/21/20 at 9:00am "daughter requested."; Ferrous Sulfate was not administered on 01/01/20 at 5:00pm "not here:, 01/03/20 at 5:00pm "held per POA", 01/07/20 and 01/09/20 at 5:00pm "held per POA", and on 01/21/20 at 9:00am "daughter requested."

Due to the volume of evidence gathered during this inspection, a separate document has been created.

Plan of Correction: On March 17, 2020 , and continually every other month, the Shenandoah Place facility nurse, will provide Refresher Course for Medication Aides or a medication based inservice/review. This class will review proper procedures for medication administration and necessary documentation to be utilized and followed. Review will include how staff will report refusals to an appropriate healthcare professional and document such. Orders and MARS will be reviewed monthly by the facility nurse to ensure residents are receiving medications per HCP orders and that orders are written appropriately. New orders will be checked by the facility nurse to assure correctness prior to merging onto the eMAR. The administrator will contact the HCP or pharmacy in question if a medication is unavailable to assure delivery and accessibility of the medication.
Weights will be monitored and obtained as directed by HCP. Weights will be documented in a designated area in the facility and reviewed monthly by the administrator to assure that they are being done and to monitor for any unusual gains or losses.

Standard #: 22VAC40-73-680-I
Description: Based upon review of residents' records, the facility failed to ensure all required information is included in the Medication Administration Record (MAR).
EVIDENCE:
1) Resident C's order for Potassium does not include a diagnosis.
2) Resident E's order for Furosemide does not include a diagnosis.
3) All orders for resident F do not include a diagnosis.

Plan of Correction: The facility nurse and/or administrator will make sure that diagnoses are included in all physician?s orders and the diagnoses are included in each medication entry on the MAR. MARs for each resident will be checked monthly to assure medication orders meet regulations as set forward in the DSS regulations.

Standard #: 22VAC40-73-860-I
Description: Based upon direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are stored in a locked area.
EVIDENCE:
1) During a walk through of the facility, the LI observed a cleaning cart unlocked and unattended in the hallway containing various cleaning supplies.
2) During a walk through of the facility, the LI observed the door to the sprinkler control room unlocked. The room contained ice melt and a gallon of paint.

Plan of Correction: 1-Housekeeping staff was directed by the facility nurse immediately regarding the storage and monitoring of cleaning materials. Going forward, cleaning cart/supplies will be within vision of staff and inaccessible to residents. Compliance will be continually monitored by the facility administrator while housekeeping staff is on shift.
2-The Riser Room Door was immediately locked by the administrator, a plan will be put into place for the staff in charge to check doors of each room holding hazardous materials to be checked each shift. Documentation of this will be maintained at the front desk in a designated book. Going forward any room with hazardous supplies will be locked in compliance with regulations and documented each shift in a designated place within the facility.

Standard #: 22VAC40-73-930-D
Description: Based upon review of resident's records and an interview, the facility failed to ensure the inability to use the signaling device is included on the Individualized Service Plan (ISP).
EVIDENCE:
1) The ISP for residents A, N and O do not include the inability to use the call bell system.
2) The LI interviewed the administrator who stated that these residents are non-ambulatory and have an inability to use the signaling device.

Plan of Correction: The administrator will assure that ISP?s will include a client?s inability to utilize the call bell system to obtain staff assistance and measures taken to guarantee client care . For residents unable to utilize call bell; visual checks will be performed hourly and documented appropriately within the facility. ISPs will be reviewed yearly and as warranted by condition change.

Standard #: 22VAC40-73-950-E
Description: Based upon documentation and an interview, the facility failed to ensure that at least every six months, all residents participated in a semi-annual review of the emergency preparedness and response plan.
EVIDENCE:
1) Documentation on file indicates a review was completed on 11/27/19 with facility staff and did not include a review with the residents.
a. The LI conducted an interview on 02/25/20 with the administrator who stated she was not aware a review had to be completed with all residents.

Plan of Correction: The facility administrator or designated person will review the Emergency Preparedness Plan semi-annually in March and September of each year with the residents of Shenandoah Place. Documentation of the review will be maintained within the facility in the Fire Book for inspection by DSS.

Standard #: 22VAC40-73-970-A
Description: Based on documentation and an interview, the facility failed to ensure fire and emergency evacuation drills are in accordance with the current edition of the Virginia Statewide Prevention Code.
EVIDENCE:
Documentation of facility fire and evacuation drills were conducted on 11/13/19 at 7:05pm and on 01/30/20 at 6:40am. There is no documentation of a fire and evacuation drill being completed on the night shift for the month of December.

Plan of Correction: Facility Administrator will assure that Fire Drills will be completed monthly on rotating shifts to involve every shift in each quarter. Documentation of the drill including time, location of fire, staff involved and number of residents participating as well as any special conditions encountered will be documented in the Fire Book and maintained in the office at Shenandoah Place.

Standard #: 22VAC40-73-980-A
Description: Based upon direct observation, the facility failed to ensure the first aid kits included all required items.
EVIDENCE:
1) The first aid kit in the administrator's office did not contain a blanket, CPR mask, cold pack, disposable gloves, roller gauze, hand sanitizer, plastic bags, scissors, small flashlight with extra batteries, thermometer, triangular bandages, tweezers and a first aid manual.
2) The first aid kit in the facility kitchen did not contain antiseptic ointment, CPR mask, roller gauze, hand sanitizer, scissors, small flashlight with extra batteries, thermometer and triangular bandages.

Plan of Correction: First Aid Kits will include all items as listed in regulation. The first aid kits will be checked monthly by the facility nurse. Documentation of the checks will be kept at a designated place in the facility.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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