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. 16, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Criminal History Record Report

Comments:

A non-mandated focused monitoring inspection was initiated on 08/16/21 and concluded on 08/19/21 The acting administrator was contacted by telephone to conduct the investigation. The acting administrator reported the current census as 18.The licensing inspector emailed the acting administrator a list of items required to complete the investigation. The evidence gathered during the inspection determined non-compliance(s) with standards or law, and violations were issued. Upon the 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 re-occurrence; 3) person(s) responsible for implementing each step and monitoring preventative measures; 4) the date by which the non-compliance will be corrected.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that Individual Service Plans (ISPs) included all required components. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident 1, dated 05/15/21 shows the resident is assessed as needing staff assistance with dressing. The ISP dated 05/12/21 indicates no assistance is needed. The Uniform Assessment Instrument (UAI) for resident 1, dated 05/15/21 shows the resident is assessed as needing medication administration by professional nursing staff. The ISP dated 05/12/21 indicates medication administration by a registered medication aide. 2. The Uniform Assessment Instrument (UAI) for resident 2, dated 11/10/20 shows the resident is assessed as needing mechanical assistance with walking. This is not addressed on the ISP dated 11/10/20. The Uniform Assessment Instrument (UAI) for resident 2, dated 11/10/20 shows the resident is assessed as disoriented to some spheres some of the time. The ISP dated 11/10/20 indicates resident is oriented to all spheres. The Uniform Assessment Instrument (UAI) for resident 2, dated 11/10/20 shows the resident is assessed as needing medication administration by professional nursing staff. The ISP dated 11/10/20 indicates medication administration by a registered medication aide.
Plan of Correction:	As part of the change of administrators at SP, all UAIs and service plans were being re-written prior to this inspection. Resident 1, as identified in the violation, is not currently in the facility, but in a rehab unit, therefore his documents were not reviewed. The person reviewing documents did not know this individual and was unable to complete the documents without firs evaluating, which would be done upon return to the facility from the rehabilitation unit.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure a criminal history report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The criminal history report for staff 1 is dated 08/17/21. Staff 1 started employment on 07/13/21. 2. The criminal history report for staff 2 is dated 08/17/21. Staff 2 started employment on 07/12/21. 3. The criminal history report for staff 3 is dated 08/11/20. Staff 3 started employment on 06/14/21.
Plan of Correction:	All 3 staff mentioned in the violation were hired and began work under the previous administrator. Upon review of the staff charts by the acting administrator, it was noted that these charts lacked criminal history checks which were immediately obtained from the website.