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: June 22, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Technical Assistance:

Recommend adding "call 911" to MAR for nitroglycerin orders as it pertains to residents D and F; add "take pulse" and hold per instructions obtained from resident's physician.

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 focused monitoring inspection was initiated on 06/22/21 and concluded on 07/06/21. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 16. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed a selected portion of six resident records ,medication certification for one staff, and incident reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance; 2) measures to prevent reoccurrence; 3) person(s) responsible for implementing each step and monitoring preventative measures; 4) The date by which non-compliance will be corrected.

Violations:

Standard #:	22VAC40-73-440-D
Description:	Based upon review of residents' records, the facility failed to ensure the Uniform Assessment Instrument (UAI) is included all required information. FINDINGS: 1) The UAIs for residents A and B do not include phone number and social security number. 2) The UAIs for residents D and F do not include a social security number. 3) The UAI for resident E does not include address, phone, date of birth, and section for ambulation assistance is not completed.
Plan of Correction:	Administrator to review and correct UAI.
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 Individualized Service Plan (ISP). FINDINGS: 1) The Uniform Assessment Instrument (UAI) for resident A indicates a wheelchair is needed for toileting and transferring. The ISP indicates mechanical assistance of walker a. The UAI indicates wheelchair is used for long distances. b. Physician's order dated 06/03/21 indicate resident has special diet of no added sugar; this is not indicated on the ISP. 2) The UAI for resident C indicates wandering less than weekly. This is not indicated on the ISP. 3) The UAI for resident D indicates a wheelchair is needed for toileting. The ISP indicates on the transferring section only use of walker in bathroom. a. The UAI for resident D indicates mechanical and human assistance is needed with stairclimbing. This is not indicated on the ISP. 4) The ISP for resident F indicates mechanical assistance of wheelchair walker and handrails for toileting. The ISP indicates on the transferring section use of walker and handrails in bathroom. a. The UAI indicate resident uses urinal at night. This is not indicated on the ISP. b. The UAI indicates no assistance is needed with wheeling. The ISP indicates staff will provide physical assistance with wheeling. c. The UAI indicates mechanical assistance is needed with stairclimbing. This is not indicated on the ISP. d. The physical exam dated 05/24/21 indicates special diet of no added salt regular texture. The ISP indicates regular diet.
Plan of Correction:	Administrator/LPN to review and correct care plans.
Standard #:	22VAC40-73-450-D
Description:	Based upon review of residents' records, the facility failed to ensure services provided by hospice are included on the Individualized Service Plan (ISP). FINDINGS: The hospice plan of care for resident C indicates resident receives skilled nursing services, aide services, chaplain and volunteer services. a. The ISP indicates nursing oversight for co-morbidities, care and support for resident and family.
Plan of Correction:	Administrator/LPN to review and correct care plans.
Standard #:	22VAC40-73-930-D
Description:	Based upon review of residents' records, the facility failed to indicate the inability to use the call bell system on resident B's Individualized Service Plan (ISP) FINDINGS: 1) The physical exam for resident B dated 04/03/21 indicates resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person. a. The physical exam also indicates resident B has a history of head trauma, pelvic fracture, arm and hip fracture. b. The Uniform Assessment Instrument (UAI) for resident B indicates resident is disoriented with short term memory loss. c. The ISP does not indicate the inability to use the signaling device and specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.
Plan of Correction:	Administrator/LPN to review and correct care plans.