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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: May 26, 2020

Complaint Related: No

Areas Reviewed:
22VAC40-73 PERSONNEL
22VAC40-73 STAFFING AND SUPERVISION
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-90 The Criminal History Record Report

Technical Assistance:
1) Variation of time for night shift fire drills
2) Ensure orders for O2 saturation and blood pressure include parameters as to when to notify physician.
3) UAI to indicate medication administration by lay person to include RMA

Comments:
This inspection was completed by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia.
A monitoring inspection was initiated on 05/26/20 and concluded on 06/02/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported a census of 21. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three staff records, three resident records, April and May medication administration records for a selected portion of residents, submitted by the facility to ensure documentation was complete. The facility is currently on a provisional license status. Information gathered during this focused monitoring inspection determined non-compliance with applicable standards or law and twelve violations were documented on the violation notice issued to the facility. Following administrative review, the findings of this inspection report, have been amended and revised on 11/19/20. If you have any questions, please contact the LI at (540) 332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:
Standard #: 22VAC40-73-150-C
Description: Based upon review of residents' records, submitted documentation from the facility, the administrator failed to ensure that care is provided to residents in a manner that protects their health, safety and well-being and maintaining compliance with applicable laws and regulations.
EVIDENCE:
1) The facility was placed on a provisional license status at the renewal inspection completed on 02/25/20 and was required to submit and intensive plan of correction due to the severity of the violations.
2) The information gathered during this monitoring inspection (refer to the Violation Notice in this report), show there are ongoing systemic issues as relates to the health, safety and well-being of the residents and maintaining compliance with applicable laws and regulations.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-200-B
Description: Based upon review of residents' record, the facility failed to ensure staff caring for residents with special health care needs only provide services within the scope of their practice and training.
EVIDENCE:
1) Notification was sent to this LI on 04/21/20 regarding a coccyx wound on resident K.
2) The Medication Administration Record (MAR) for April and May indicate Registered Medication Aides provided wound care by applying Desitin cream and Greer's Goo to the open area.
a. Documentation in the MAR for resident K indicates direct care staff applied Desitin to "an open area on resident's bottom on 04/20/20 at 7:53pm; 04/21/20 at 8:01pm and 04/22/20 at 7:27pm and on 05/13/20 at 11:19pm "resident has open area on left side of bottom, his patch from home health fell off."
b. Documentation in the MAR for resident K indicates direct care staff applied Greer's Goo on 04/9/20 at 3:57pm " area open on buttocks."; 04/20/20 at 10:33am "area on buttocks open."; 04/23/20 at 9:45pm "resident complains of soreness with open area on buttocks."; 04/24/20 at 10:27pm "resident's bottom red and has an open area on left side."; 04/25/20 at 1:28am "bottom still red and open, documented on shift report."; 04/27/20 at 8:28am "after shower for open area."; 04/27/20 "open area on the top left side of resident's bottom."; 04/28/20 at 12:41am "resident has an open area on left side of his bottom."; 05/03/20 "open area on left side of resident's bottom."; 05/11/20 at 10:28am "open area on bottom." Results documented at 11:42am "still open, Nurse measured and aware."
3) The Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides prohibits wound care. Page 8 of the curriculum indicates "Medication Aides are not trained to perform wound care or dressing changes, as this is considered a skilled treatment and not a medication."

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-280-A
Description: Based upon a review of the facility schedule, residents' records and submitted documentation, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident.
EVIDENCE:
1) A review of the facility schedule from 05/01/20 through 05/29/20 indicates there are only two direct care staff on duty for second and third shift.
a. Documentation and review of resident's records indicate there are two residents who require assistance of two staff and five residents who are non-ambulatory by reason of physical or mental impairment and are not capable of self-preservation without the assistance of another person.
2) Resident A has an order for daily weights. Documentation in the MAR indicates weight was not obtained on 04/15/20 at 9:10am "residents are in quarantine in rooms at this time and we don't have enough help with helping in the kitchen too."
a. Documentation in the MAR at 9:51am indicates "Quarantined in rooms right now and not enough staff to do it."
3) Resident C has an an order for weekly weights. Documentation in the MAR indicates this was not obtained on 04/15/20 at 8:12am "resident quarantined in rooms right now and not enough staff to do it."
3) Resident D has an order for weekly weights. Documentation in the MAR indicates this was not obtained on 04/15/20 at 9:53am "resident quarantined in rooms and not enough staff to do it."
4) Resident H has an order for daily weights. Documentation in the MAR indicates this was not obtained on 04/15/20 at 8:51am "Resident quarantined in rooms at this time and we don't have enough help with helping in kitchen too.
5) Refer to 22VAC-40-73-680D for additional information.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-280-C
Description: Based upon a review of the facility schedule, residents' records and submitted documentation,the facility failed to ensure an adequate number of staff are on the premises at all times to implement the approved fire and emergency evacuation
EVIDENCE:
1) A review of the facility schedule from 05/01/20 through 05/29/20 indicates there are only two direct care staff on duty for second and third shift.
a. Documentation and review of resident's records indicate there are two residents who require assistance of two staff and five residents who are non-ambulatory by reason of physical or mental impairment and are not capable of self-preservation without the assistance of another person.
2) Resident A has an order for daily weights. Documentation in the MAR indicates weight was not obtained on 04/15/20 at 9:10am "residents are in quarantine in rooms at this time and we don't have enough help with helping in the kitchen too."
a. Documentation in the MAR at 9:51am indicates "Quarantined in rooms right now and not enough staff to do it."
3) Resident C has an an order for weekly weights. Documentation in the MAR indicates this was not obtained on 04/15/20 at 8:12am "resident quarantined in rooms right now and not enough staff to do it."
3) Resident D has an order for weekly weights. Documentation in the MAR indicates this was not obtained on 04/15/20 at 9:53am "resident quarantined in rooms and not enough staff to do it."
4) Resident H has an order for daily weights. Documentation in the MAR indicates this was not obtained on 04/15/20 at 8:51am "Resident quarantined in rooms at this time and we don't have enough help with helping in kitchen too.
5) Refer to 22VAC-40-73-680D for additional information.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-440-D
Description: Based upon review of residents' records, the facility failed to ensure the UAI is completed as required.
EVIDENCE:
1) The UAI for resident A indicates confusion to some spheres all the time. The spheres are not identified.
a. The section for mobility is incomplete.
2) The UAI submitted for resident K indicates a reassessment date of 03/04/2019.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-450-C
Description: Based upon review of residents' records, the facility failed to ensure the assessed needs of the resident are included on the ISP.
1) The UAI for resident A indicates physical and mechanical assistance is needed with walking. This is not reflected on the ISP.
a. The UAI indicates only supervision is needed with transferring. The ISP indicates assistance of one person , the use of handrails, walker and furniture.
2) The UAI for resident B indicates assistance is needed with dressing. The ISP indicates the resident is independent.
a. The UAI indicates incontinence of bladder. This is not reflected on the ISP.
b. The physical for resident B indicates a heart healthy diet. This is not identified on the ISP.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-640-A
Description: Based upon review of residents' records, the facility failed to implement procedures in the medication management plan to ensure accurate and complete documentation and timely documentation of effectiveness of PRN medications.
EVIDENCE:
1) The facility medication management plan indicates a complete order shall include the name of the client, name, strength, dose and route of the medication, how often to give, and any special instructions. A diagnosis, condition, or specific indication shall be on record for each medication prescribed.
a. Please refer to regulation 22 VAC-40-73-650B in the Violation Notice section of this report.
2) The facility medication management plan indicates a daily review of the Medication Administration Records (MARs) by the director of nursing, administrator or the medication aide supervisor shall be performed to ensure accurate and complete documentation to include timely documentation of effectiveness of PRN medicaitons.
2) Please refer to violation 22-VAC-40-73-680I in the Violation Notice Section of this report.
3) The facility medication management plan indicates there are no self-administering residents.
a. Documentation in the MAR for resident E indicates self-administration of Humulin on 05/06/20 at 4:23pm; 05/12/20 at 5:28pm; 05/14/20 at 5:51pm; 05/17/20 at 4:59pm.
4) The medication management plan indicates Any Registered medication aide on duty at the above times will contact the DON with the variation in med pass time and receive verbal consent/denial to pass the medication in question outside of the hour before, hour after time frame. No medication will be administered outside of the given time frame without the prior approval of the director of nursing. Documentation on the eMAR will include the reason for the early/late administration as well as a statement reflecting the consent to administer/hold the medication.
a. Resident E has an order to administer Humulin prior to meals. Meal times at the facility are at 8:00am, 12:00pm and 5:00pm.
b. Documentation in the MAR indicates Humulin was administered on 05/02/20 at 10:28am; 05/03/20 at 9:44am; 05/04/20 at 9:05am; 05/05/20 at 9:10am;05/08/20 at 9:19am; 05/13/20 at 9:26am; 05/14/20 at 9:39am; 05/15/20 at 9:06am; 05/17/20 at 9:37am; 05/18/20 at 9:20am; 05/19/20 at 9:10am and 05/26/20 at 9:57am.
c. Documentation in the MAR indicates that unistik safety lancet was used on 05/26/20 at 10:02am and that blood sugar was taken after resident E had eaten.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-650-B
Description: Based upon review of residents' records, the facility failed to ensure physician's orders in the electronic MAR contain all required information.
EVIDENCE:
1) Potassium and Citrate orders for resident B effective 03/24/20 do not include diagnoses.
2) Ciprofloxacin order for resident D effective 03/26/20 does not include a diagnosis.
3) Amoxicillin order for resident E effective 03/31/20 does not include a diagnosis.
4) Ondansetron order for resident F effective 01/25/19 does not include a diagnosis; Lorazepam order effective 04/30/20 does not include a diagnosis.
5) Buproprion order for resident G effective 05/26/20 does not include a diagnosis; Lorazepam order effective 03/18/20 does not include route or frequency.
6) Vitamin D-3 order for resident I effective 03/20/20 does not include a diagnosis.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-680-D
Description: Based upon review of residents' Medication Administration Records (MARs), the facility failed to ensure medications are administered in accordance with 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 A has an order for daily weight-Notify MD if weight gain is greater than 3lbs in one day or 5lbs in one week.
a. Documentation in the MAR indicates weights were not obtained on 04/12/20 and 04/13/20 due to residents' being confined to their rooms.
b. Documentation indicates weight was not obtained on 04/11/20 "couldn't get an accurate weight at this time."
c. Documentation indicates weight was obtained on 04/14/20 and recorded as 150lbs.
d. Documentation indicates weight was 144.4 on 05/12/20, 146 on 05/20/20 and 151.4 on 05/22/20. There is no documentation of physician notification in the MAR.
2) Resident B has an order for compression stockings to be put on every morning at 8:00am and be removed every evening at 8:00pm.
a. Documentation in the MAR on 05/07/20 at 8:36am "hasn't gotten out of bed yet." Documentation at
9:08pm "Not on to remove."
b. Documentation in the MAR on 05/15/20 at 9:05am "hasn't gotten out of bed yet." Documentation at
7:53pm "Not on to remove."
c. Documentation in the MAR on 05/17/20 at 9:00am "not on." Documentation at 8:30pm "resident not wearing them."
d. Documentation in the MAR on 05/18/20 at 9:49am "not on." Documentation at 8:46pm "resident did not have one to remove."
e. Documentation in the MAR on 05/24/20 at 9:25am "hasn't gotten out of bed yet." Documentation at
8:14pm "resident did not have on to be removed."
3) Resident B has the following order effective 03/13/20: Fludrocortisone 0.1mg-Take one tablet by mouth three times a day to hypertension. Hold for systolic blood pressure 150 or greater.
a. Documentation in the MAR indicates BP was 164/96 at 9:48pm and medication was administered.
b. Documentation in the MAR indicates BP was 164/99 at 6:40am and medication was administered.
c. Documentation in the MAR indicates blood pressure was 204/100 on 04/28/20 at 10:26pm and medication was administered. There is no documentation of a re-check.
4) Resident B has the following order: Fludrocortisone 0.1mg-Take 0.5 tablets (0.05mg total) by mouth daily for postural hypotension. Hold for systolic blood pressure 150 or greater.
a. Documentation in the MAR indicates blood pressure was 191/87 on 05/24/20 at 9:18am and medication was administered.
b. Documentation in the MAR indicates blood pressure was 189/101 on 05/26/20 at 10:15am and medication was administered.
c. Documentation in the MAR indicates blood pressure was 195/96 on 05/27/20 at 9:07am and medication was administered.
5) Resident C has an order for TED Hose to be applied in the morning and removed in the evening.
a. Documentation in the MAR indicates 04/03/20 "not put on, resident will be getting a shower this evening."; 04/17/20 "shower day"; 05/01/20 "shower."; 05/12/20 "resident's TED hose were left in the sink from being washed out last night and are not dry."; 05/15/20 "shower"; 05/22/20 "resident has shower this morning."; 05/26/20 "resident getting a shower this morning."
6) Resident C has an order for weekly weights on Wednesday. Documentation in the MAR indicates on 05/20/20 not completed due to "scale inaccurate."

***Due to the volume of information gathered during this monitoring inspection, a separate document has been created and is available upon request.***

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-680-I
Description: Based upon review of residents' records, the facility failed to ensure all required information is documented in the Medication Administration Record (MAR).
EVIDENCE:
1) The MAR for resident E indicates Hydromorphone was administered on 05/05/20 at 3:50pm. Results documented at 4:54pm indicate medication was not effective. There is no documentation of follow-up.
a. The MAR for resident E indicates Hydromorphone was adminisered on 05/16/20 at 9:17pm. Results documented on 05/17/20 at 1:39am indicate medication was not effective. There is no documentation of follow-up.
b.The MAR for resident E indicates Hydromorphone was administered on 04/04/20 at 9:05pm. Results documented on 04/05/20 at 11:47am "resident states that is has not helped. I told resident I would check on him in a little to see how he is and if he needs something more. There is no documentation of follow-up.
c. The MAR for resident E indicates Hydromorphone was administered on 04/05/20 at 8:39pm. Results documented on 04/06/20 at 12:44am indicate medication was not effective. There is no documentation of follow-up
d. The MAR for resident E indicates Hydromorphone was administered on 04/06/20 at 8:21pm. Results documented at 9:38pm indicate medication was not effective. There is no documentation of follow-up.
e. The MAR for resident E indicates Hydromorphone was administered on 04/07/20 at 9:09pm. Results documented at 11:10pm indicate medication was not effective. There is no documentation of follow-up.
f. The MAR for resident E indicates Hydromorphone was administered on 04/09/20 at 9:15pm. Results documented at 10:10pm indicate medication was not effective. There is no documentation of follow-up.
g. The MAR for resident E indicates Hydromorphone was administered on 04/10/20 at 8:09pm. Results documented at 11:27pm indicate medication was not effective. There is no documentation of follow-up.
h. The MAR for resident E indicates Hydromorphone was administered on 04/11/20 at 8:49pm. Results documented at 10:49pm indicate medication was not effective. There is no documentation of follow-up.
i. The MAR for resident E indicates Hydromorphone was administered on 04/14/20 at 8:36pm. Results documented on 04/15/20 at 06:21am "resting with eyes closed."
j. The MAR for resident E indicates Hydromorphone was administered on 04/07/20 at 9:09pm. Results documented at 10:10pm indicate medication was not effective. There is no documentation of follow-up.
k. The MAR for resident E indicates on 04/16/20 PRN Hydromorphone was administered at 9:19 as resident requested for pain. Documentation at 11:46pm indicates it was administered at 8:25 but due to an emergency within the facility it was signed off late. Documentation at 11:47pm also indicates "it has helped some, but not enough." There is no documentation of follow-up.
l. The MAR for resident E indicates Hydromorphone was administered on 04/19/20 at 8:49pm. Results documented on 04/20/20 at 03:46am "resting with eyes closed."
m. The MAR for resident E indicates Hydromorphone was administered on 04/21/20 at 9:42pm. Results documented on 04/2/20 at 07:12am "resting with eyes shut."
n. The MAR for resident E indicates Hydromorphone was administered on 04/22/20 at 10:13pm. Results documented on 04/23/20 at 06:20am "resting with eyes closed."
o. The MAR for resident E indicates Acetaminophen was administered on 05/20/20 at 5:24pm for pain. Results documented at 7:21pm "resident states very little relief; sleeping when RMA entered room. There is no documentation of follow-up.
p. The MAR for resident E indicates Alprazolam was administered on 05/14/20 at 8:13pm for pain. Results documented at 10:13 indicate it was not effective. There is no documentation of follow-up.

**Due to the volume of information gathered during this inspection, a separate document has been created and is available upon request.**

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-700-1
Description: Based upon review of residents' records, the facility failed to ensure oxygen orders identified the source.
EVIDENCE:
1) The oxygen order for resident A effective 02/14/20 does not identify the source.
2) The oxygen order for resident H effective 12/08/2019 does not identify the source.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-90-40-F
Description: Based upon review of staff records, the facility failed to ensure the criminal history report on file for staff A was within the 90 day requirement.
EVIDENCE:
Staff A was a re-hire effective 04/24/20.
a. The criminal history on file at the facility is dated 10/11/19.

Plan of Correction: Not available online. Contact Inspector for more information.

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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