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: Aug. 14, 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 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:

Ensure blood pressure orders include parameters of when to notify physician; high and low. Ensure the UAI indicates medication administration by lay person to include RMA.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 08/14/20 and concluded on 08/26/20. The facility is currently on a provisional license and an intensive plan of correction. The administrator was contacted by email to initiate the inspection. Documentation indicated the current census is eighteen. The inspector emailed a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, physicians' orders and July and August medication administration records for a selected number of residents to ensure all documentation was complete. A review was completed of criminal history reports, the facility medication management plan and staffing schedule. Information gathered during this inspection determined non-compliance with applicable standards or law, and 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.

Violations:

Standard #:	22VAC40-73-70-B
Description:	Based upon review of residents' records, the facility failed to ensure incident reports include all required information. EVIDENCE: 1) The incident report for resident L indicates a fall on 08/26/20. There is no time indicated 2) The incident report for resident F does not indicate a date.
Plan of Correction:	Not available online. Contact Inspector for more information.
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. 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. 2) The information gathered during the 05/26/20 monitoring inspection as well as this inspection show there are ongoing systemic issues as it 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' records, 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) The Medication Administration Record for resident I has the following order: Hydrocolloid Foam 4x4 dressing-Apply to sacral wounds weekly. a. Documentation in the MAR indicates on 07/06/20, 07/13/20, 07/20/20 and 08/17/20 that the dressing was applied by a registered medication aide. b. 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." c. Hospice notes dated 08/17/20 indicates "Stage II to lower left buttock: to be changed weekly and as needed if soiled or falls off. Facility staff to complete wound care in hospice nurse absence."
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-280-A
Description:	Based upon review of the facility schedule, residents' records and submitted documentation, the facility failed to have staff adequate in knowledge, skills, 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 08/01/20 through 08/21/20 does not consistently indicate there are three direct care staff working each shift as previously discussed with owner. 2) Based upon a review of residents' records, previously submitted documentation and a phone interview with the administrator on 08/28/20, there are two residents who require the 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. 3) The Medication Administration Record (MAR) for resident E indicates Aprazolam (scheduled at 9:00pm for insomnia) was administered at 10:29 on 08/14/20. Documentation in the MAR "given late due to resident emergency." 4) The MAR for resident F indicates Famotodine (scheduled for 9:00pm) was administered at 10:30pm on 08/14/20. Documentation in the MAR "given late due to resident emergency." 5) The MAR for resident G indicates Gapapentin (scheduled at 9:00pm for lower pack pain) and Olanzapine (scheduled at 9:00pm for Bi-polar disorder) were administered at 10:30pm. Documentation in the MAR "administered late due to resident emergency." 6) The MAR for resident K indicates Metoprolol (scheduled at 9:00pm for stroke prevention) and Morphine (scheduled at 9:00pm for sever pain) were administered at 10:29pm. Documentation in the MAR "administered late due to resident emergency." 7) Per submitted documentation and a phone interview with the administrator on 08/28/20, the resident who had an emergency was vomiting and requires the assistance of two staff. 8) Resident J has the following order: Irbesartan 75mg- Take one by mouth twice a day for hypertension and congestive heart failure. Hold if systolic blood pressure is less than 105. Scheduled times on the MAR are 8:00am and 5:00pm. a. Documentation in the MAR indicates resident's blood pressure at 203/93 on 08/03/20 at 5:43pm; 190/88 on 08/09/20 at 8:26am; 200/94 on 08/10/20 at 8:57am a re-take indicates blood pressure at 180/94, 201/83 on 08/15/20 at 8:51am a re-take indicates blood pressure at 188/86, 196/86 on 08/18/20 at 8:39am, 189/82 on 08/19/20 at 4:59pm, 196/80 on 08/21/20 at 4:58pm, 191/91 on 08/23/20 at 8:12am and 192/81 on 08/23/20 at 4:35pm. a. There is no documentation of physician notification in the MAR for the month of August for elevated blood pressures. 9) Please refer to violations 22 VAC-40-73-150C, 22 VAC-40-73-200B, 22 VAC-40-73-640A, 22 VAC-40-73-280C, 22VAC 40-73-470 F and 22VAC-40-73-680D as it relates to staff adequate in knowledge, skills and abilities.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-280-C
Description:	Based upon review of 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 plan. EVIDENCE: 1) A review of the facility schedule from 08/01/20 through 08/21/20 does not consistently indicate there are three direct care staff working each shift as previously discussed with owner. a. Submitted documentation, a review of residents' records and a phone interview with the administrator on 08/28/20 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. b. The LI interviewed the administrator on 08/28/20 who stated there is one device on hand at this time that can be utilized by one staff in the event of an evacuation. The device is to assist the two residents who require assistance of two staff. At this time another device is being made. c. Refer to violation 22 VAC-40-73 280A relating to late medications due to resident emergency.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-C
Description:	Based upon review of submitted documentation, the facility failed to ensure documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls was completed as required. EVIDENCE: 1) The incident report for resident M indicates a fall on 08/20/20 at 11:00pm. There is no documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. 2) The incident report for resident O indicates a fall on 07/06/20 at 8:05pm. There is no documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based upon review of staff records, the facility failed to ensure the assessed needs of the resident are included on the Individualized Service Plan (ISP). EVIDENCE: 1) The Uniform Assessment Instrument (UAI) for resident A indicates mechanical assistance is needed with stair climbing and walking. This is not indicated on the ISP. 2) Resident B is prescribed Quetiapine twice a day for behavioral problems effective 02/14/20. The UAI indicates appropriate behaviors. The UAI was completed on 03/26/20 and the ISP updated effective 08/05/20. a. The ISP does not specify frequency of rounds due to resident's inability to use the call bell system. Resident is non-ambulatory. b. Hospice plan of care dated 08/02/20 indicates need for skilled teaching related to wound. This is not reflected on the ISP. 3) The UAI for resident C indicates resident needs supervision with dressing. The ISP indicates resident is independent. a. Stair climbing section on the UAI indicating assistance is required or not required is not completed but also indicates mechanical assistance is needed. This is not indicated on the ISP. b. Home health services is still indicated on the ISP effective 02/13/20. Resident is no longer receiving home health services. c. The UAI and ISP indicate supervision and mechanical assistance is needed with mobility. The ISP indicates the resident travels outside of the facility independently and ambulates independently. d. It is not indicated on the ISP that resident or legal representative received a copy.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-470-F
Description:	Based upon review of documentation, the facility failed to ensure the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. EVIDENCE: 1) The incident report for resident B indicates a fall on 07/11/20 at 10:35am. Documentation indicates first aid was administered and resident complained of head hurting. The incident report indicates resident was not sent to the hospital and hospice, DON and administrator notified. a. There is no further documentation indicating resident was seen by a health care professional immediately. 2) Incident reports that were requested by the LI and submitted by the administrator show that resident L sustained falls on 08/26/20 (no time indicated), 08/20/20 at 8:18am 07/01/20 at 9:40pm, 07/04/20 at 3:30pm, 07/08/20 at 6:25pm, 07/14/20 at 7:45pm, 07/18/20 at 6:56pm and 07/31/20 at 5:00am. a. The incident reports indicate administrator notified, but do not indicate resident was sent to the hospital or seen by an nurse.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based upon review of the facility medication administration plan and medication administration records, the facility failed to implement procedures as outlined in the plan. EVIDENCE: 1) 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 PRN medications. a. Please refer to violation 22-VAC-40-73-680I in the Violation Notice section of this report. 2) The medication management plan indicates any registered medication aide on duty at above listed 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 early/late administration as well as a statement reflecting the consent to administer/hold the medication. a. Please refer to 22 VAC-40-73-280A in the Violation Notice section of this report as it relates to late medication. 3) The medication management plan indicates No medication, prescription or over the counter, diet, medical procedure, or treatment shall be started, changed or discontinued without an order by the physician. a. Please refer to 22 VAC-40-73-650A in the Violation Notice section of this report as it relates to physician's orders.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-A
Description:	Based upon a review of residents' records, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medication. EVIDENCE: 1) Resident A has the following order: Epsom salt granules 544: Warm Epsom salt soaks two times a day for 15 minutes to left foot for left great ingrown toenail. a. Documentation in the MAR indicates this was not done on 08/05/20 at 9:00pm "Dr. discontinued", 08/06/20 at 9:00am "discontinued by Dr.", 08/06/20 at 9:00pm "order discontinued", 08/07/20 at 9:00am "it's to be discontinued per resident and that she doesn't want to take it anymore.", 08/07/20 at 9:00pm "order discontinued", 08/09/20 at 9:00pm "resident no longer does." b. The order to discontinue the Epsom Salts is dated and signed by the physician on 08/10/20. 2) Resident B has the following order: Desitin Daily-apply four times daily for irritation. a. Documentation in the MAR indicates this was not administered on 07/31/20 at 6:00pm "held applying other cream per LPN", 07/30/20 at 9:00pm "held due to giving another cream", 07/31/20 at 6:00pm "held applying other cream", 07/31/20 "held applying other cream, 08/04/20 6:00pm "area has no irritation", "08/01/20 at 6:00pm "per nurse use other cream."
Plan of Correction:	Not available online. Contact Inspector for more information.
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 A has the following order: Minerin Cream 4oz-May apply as often as needed for dry or cracked skin under skilled nurse (not medication aide) supervision. a. Documentation by medication aides in the Medication Administration Record (MAR) indicates on 07/02/20 at 9:08am "resident applied herself." ,07/11/20 at 8:26am "resident stated she applied.", 07/25/20 at 8:47am "resident applied.", 07/26/20 at 8:44am "resident applied." 2) Resident A has an order to check blood glucose at breakfast, lunch and dinner. a. Documentation in MAR for 07/17/20 at 8:32am "obtained after resident ate breakfast." 3) Resident B has the following order: Lorazepam every 4 hours as needed for anxiety and restlessness. a. Documentation in the MAR indicates medication was administered on 07/07/20 at 9:11am anxiety-figety, running into people, picking up stuff, not saying nice things to others." 4) Resident C has the following order: Systane eye drops- Administer one drop into both eyes four times a day for dry eyes. a. Documentation in the MAR indicates medication was not administered twice on 08/8/20 and 08/09/20, once on 08/10/20, three times on 08/11/20, once on 08/12/20, twice on 08/13/20, four times on 08/14/20, three times on 08/15/20, once on 08/16/20, 08/17/20 and 08/18/20. Documentation the in MAR "put in left eye, right eye has different drops and "only applied to left eye." 5) Resident C has the following order: Polymyxin drops-instill into right eye every 4 hours while awake. a. Scheduled times on MAR for administration include 1:00am and 5:00am. 6) Resident D has the following order: Ensure three times a day;underweight. a. Documentation in the MAR indicates Ensure was not given to resident on 08/03/20 at 12:00pm "ate good breakfast." b. There are nine refusals documented in the MAR for August and five refusals documented for July. c. There is no documentation in the MAR of physician notification. 7) Resident D has the following order: Daily weight-Notify MD if weight gain is greater than 3lbs in one day or 5lbs in a week. a. Documentation in the MAR indicates resident's weight at 147.5 on 07/02/20 and 150.5 on 07/03/20. There is no documentation of physician notification. b. Documentation in the MAR indicates resident's weight at 149.5 on 07/26/20 and 152.5 on 07/27/20. There is no documentation of physician notification. 8) Resident E has the following order: Check blood sugar once in the mornings for diabetes scheduled for 7:30am. a. Documentation in the MAR on 07/19/20 at 8:53am "resident stated already had a coke" b. Documentation in the MAR on 07/30/20 at 8:58am "already had breakfast." 9) Resident F has the following order: Daily weight-notify MD if greater than 3lbs in a day. a. Documentation in the MAR indicates resident's weight at 115 on 08/05/20 and 118 on 08/06/20. b. There is no documentation of physician notification. 10) Resident G has the following order: Linzess 14mg-Take 1 by mouth every morning 30 minutes before breakfast. a. Documentation in the MAR on 08/06/20 at 10:19am indicates medication was not administered "too close to lunch time dose." 11) Resident G has duplicate PRN orders for A&D ointment. **Due to the volume of information gathered during the 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 documentation is documented in the Medication Administration Record (MAR) EVIDENCE: 1) The MAR for resident B indicates Tylenol was administered on 07/17/20 at 3:22pm. Results documented at 5:40pm indicates "still complaining of back pain and temp 100.1" a. There is no documentation of follow-up. 2) Resident C has an order for Prednisoline drops. There is no diagnosis indicated on the MAR.
Plan of Correction:	Not available online. Contact Inspector for more information.