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: Sept. 4, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 monitoring inspection was initiated on 09/04/20 and concluded on 09/10/20. A self-report was received by the department regarding allegations in the areas of health and safety. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice. Following administrative review, the findings of this inspection report, have been amended and revised on 11/19/20.

Violations:

Standard #:	22VAC40-73-150-C
Description:	Based upon review of residents' records and 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 required to submit and intensive plan of correction based on issues with health and safety as it relates to medication and treatment. 2) The information gathered during this inspection, the monitoring inspections completed on 05/26/20 and 08/14/20 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. 3) The administrator reported to the LI on 09/04/20 that resident A had been seen by the home health nurse earlier that morning and upon removal of dressing from the resident's right leg, maggots were observed in the wound. a. A review of home health notes from 07/01/20 through 09/04/20 indicate resident A has been receiving ongoing wound care. Documentation from home health visit note dated 09/04/20 indicates "dressing on leg had dried blood from visual inspection. Removed old dressing and maggots were in the wound bed, on leg and old dressing." b. The last report received in the licensing office indicating resident A had a wound was on 03/09/20. c. The facility employs two licensed health care professionals, one of which is also the administrator.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-280-A
Description:	Based upon review of residents' Medication Administration Records (MARS), and an interview with the administrator, 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) The MAR for resident A indicates Acetaminophen due at 8:00am was not administered until 10:48am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." a. The MAR for resident A indicates Buspirone, Digestive probiotic, Docusate, Famotidine, Ferrous Sulfate, Furosemide, Linzess, Vitamin C and Vitamin D due at 9:00am, were not signed off and administered until after 10:48am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." b. The MAR for resident A indicates Morphine scheduled every 12 hours at 9:00am and 9:00pm for severe pain, was not administered until 10:42am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." 2) The MAR for resident B indicates Senna, Sertraline, Vitamin D, Aspirin, Bruproprion, Eliquis, Famotidine, Januvia, Polyethylene Glycol and Ramipril due at 8:00am were not administered until after 9:48am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." 3) The MAR for resident C indicates Acetaminophen, Aspirin, Docusate, Losartan, Senna, Vitamin B-12 and Vitamin D-3 were not administered until 10:23am. Documentation in the MAR "late due to resident care, admin aware, will notify md." 4) The MAR for resident D indicates Carvedilol, Ferrous Sulfate, Lisinopril, Magnesium Oxide, Potassium Chloride, Oxycodone and Vitamin D-3 due at 9:00am, were not administered until after 11:19am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." 5) The LI interviewed the administrator on 09/08/20 via phone and she indicated "the day shift RMA had called out for 09/04/20 and the Registered Medication Aide (RMA) who stayed over from night shift was not familiar with the residents' medications.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based upon review of the facility medication management plan and medication administration records, the facility failed to implement procedures as outlined in the plan. EVIDENCE: 1) The medication management plan indicates any registered medication aide on duty at above listed times will contact the DON with 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. a. The medication management plan indicates any registered medication aide on duty will contact the DON with the variation in med pass time and receive verbal consent or denial to pass the medication outside of the hour before, hour after time frame. Documentation in the eMAR will include the reason for the early/late medication as well as a statement reflecting the consent to administer or hold the medication. a. Please refer to violation 22 VAC-40-680C in the Violation Notice section of this report as it relates to late medication. 2) The medication management plan indicates a daily review of the Medication Administration Records (MARs) by the director of nursing, administrator or the medication supervisor shall be performed to ensure accurate and complete documentation to include timely documentation of PRN medications. a. The addendum to the medication management plan indicates for as long as Shenandoah Place is under the Intensive plan of correction, a daily review of the eMAR will be completed and recorded on the Shenandoah Place Medication Administration Review Log by facility nurse and/or administrator. b. Please refer to 22 VAC-40-73 680C and 22 VAC-40-73-680D in the Violation Notice section of this report. 3) The medication management plan does not indicate the method for verifying that medication orders have been accurately transcribed to medication administration records (MARS) within 24 hours of receipt of a new order or change in an order. a. Please refer to violation 22 VAC-40-680D as it relates to transcription of a new order. 4) The medication management plan does not include procedures for internal monitoring of the facilty's conformance to the medication management plan.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-C
Description:	Based upon review of residents' records, the facility failed to ensure medications are administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. EVIDENCE: 1) The MAR for resident A indicates Acetaminophen due at 8:00am was not administered until 10:48am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." a. The MAR for resident A indicates Buspirone, Digestive probiotic, Docusate, Famotidine, Ferrous Sulfate, Furosemide, Linzess, Vitamin C and Vitamin D due at 9:00am, were not signed off and administered until after 10:48am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." b. The MAR for resident A indicates Morphine scheduled every 12 hours at 9:00am and 9:00pm for severe pain, was not administered until 10:42am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." 2) The MAR for resident B indicates Senna, Sertraline, Vitamin D, Aspirin, Bruproprion, Eliquis, Famotidine, Januvia, Polyethylene Glycol and Ramipril due at 8:00am were not administered until after 9:48am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." 3) The MAR for resident C indicates Acetaminophen, Aspirin, Docusate, Losartan, Senna, Vitamin B-12 and Vitamin D-3 were not administered until 10:23am. Documentation in the MAR "late due to resident care, admin aware, will notify md." 4) The MAR for resident D indicates Carvedilol, Ferrous Sulfate, Lisinopril, Magnesium Oxide, Potassium Chloride, Oxycodone and Vitamin D-3 due at 9:00am, were not administered until after 11:19am on 09/04/20. Documentation in the MAR "late due to resident care, admin aware, will notify md." 5) The LI interviewed the administrator on 09/08/20 via phone and she indicated "the day shift RMA had called out for 09/04/20 and the Registered Medication Aide (RMA) who stayed over from night shift was not familiar with the residents' medication
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) The MAR for resident A indicates Acetaminophen scheduled for 8:00am was not administered until 9:37am on 09/02/20. Documentation in the MAR "only one computer and 2 med techs." 2) Resident A has a order effective 09/03/20 at 9:15am to discontinue optilock wound care from right leg and apply Vitamin A&D to both legs. a. There is no order for Vitamin A&D on the MAR printed on 09/04/20 and received by LI at 2:21pm. b. The LI interviewed the administrator on 09/04/20 who stated "the order for Vitamin A&D had not come through and was in the process of being filled." c. The LI interviewed the administrator on 09/04/20 relating to the self-report of maggots being observed in resident A's wound. The administrator stated "there was no dressing on the area on 09/03/20 as it was not open, but the dressing was placed back on resident's right leg by unknown staff person at unknown time and then removed by home health nurse on 09/04/20 when maggots were observed in the wound." d. The home health noted dated 09/04/20 indicates "dressing on leg had dried blood from visual inspection. Removed old dressing and maggots were in the wound bed, on leg and on old dressing." 3) The MAR for resident B indicates Senna, Sertraline and Vitamin D-3, Aspirin, Burproprion, Eliquis, Famotidine, Januvia Polyethylene Glycol and Ramipril scheduled for 8:00am were not administered until 9:34am on 09/02/20. Documentation in the MAR "only one computer and 2 med techs." 4) The MAR for resident C indicates Ciprofloxin scheduled for 8:00am was not administered until 9:46am. Documentation in the MAR "only one computer and 2 med techs."
Plan of Correction:	Not available online. Contact Inspector for more information.