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:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on documentation, the facility failed to implement procedures for maintenance of scheduled II-V medications outlined in the facility's medication management plan. EVIDENCE: 1. The facility medication management plan revised 09/07/2021 #10 Maintenance of Schedule II-V Medications within Shenandoah Place indicates "medications will be counted by an RMA/LPN from the off going shift and one from the oncoming shift. The procedure will occur at the beginning and end of all three shifts in the facility. Both staff's signatures and the count obtained will be documented on either the Schedule II Count Sheet provided by the facility pharmacy or the facility's Controlled Medication Inventory sheet. 2. The Controlled Drug Administration Record for resident 1's Lorazepam does not contain initials for the off going 11-7 to 7-3 shift on 03/03/2022, 03/11/2022 and 03/12/2022. 3. The Controlled Drug Administration Record for resident 1's Lorazepam does not contain initials for the oncoming 7-3 to 3-11 shift on 02/28/2022, 03/01/2022, 03/02/2022, 03/05/2022, 03/06/2022, 03/19/2022 and 03/20/2022. 4. The Controlled Drug Administration Record for resident 1's Lorazepam does not contain initials for the off going 3-11 to 11-7 shift on 02/28/2022, 03/01/2022, and 03/02/2022. 5. The Controlled Drug Administration Record for resident 1's Lorazepam does not contain initials for the oncoming 3-11 to 11-7 shift on 03/02/2022, 03/10/2022, 03/11/2022, 03/17/2022 and 03/18/2022. 6. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the off going 11-7 to 7-3 shift on 03/03/2022, 03/10/2022, 03/11/2022 and 03/12/2022, 03/18/2022, 03/19/2022 and 03/20/2022. 7. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the off going 7-3 to 3-11 shift on 03/01/2022, 03/11/2022, 03/14/2022. 8. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the oncoming 7-3 to 3-11 shift on 02/28/2022, 03/01/2022, 03/02/2022 and 03/05/2022, 03/06/2022, 03/10/2022, 03/19/2022 and 03/20/2022. 9. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the off going 3-11 to 11-7 shift on 02/28/2022, 03/02/2022, 03/10/2022, 03/17/2022 and 03/20/2022. 10. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the oncoming 3-11 to 11-7 shift on 03/02/2022, 03/10/2022, 03/11/2022 and 03/17/2022, 03/18/2022 and 03/20/2022. 11. The Controlled Drug Administration Record for resident 3's Oxycodone does not contain initials for the off going 11-7 to 7-3 shift on 03/03/2022, 03/11/2022, 03/12/2022, 03/18/2022, and 03/19/2022. 12. The Controlled Drug Administration Record for resident 3's Oxycodone does not contain initials for the oncoming 7-3 to 3-11 shift on 03/02/2022, 03/05/2022, 03/06/2022, 03/10/2022, 03/18/2022, 03/19/2022 and 03/20/2022. 13. The Controlled Drug Administration Record for resident 3's Oxycodone does not contain initials for the off going 3-11 to 11-7 shift on 03/02/2022, 03/10/2022 and 03/18/2022. 14. The Controlled Drug Administration Record for resident 3's Oxycodone does not contain initials for the oncoming 3-11 to 11-7 shift on 03/02/2022, 03/10/2022, 03/11/2022, 03/17/2022, and 03/18/2022
Plan of Correction:	Laura Fasching, LPNM, Facility Manager, will conduct a weekly review, on Wednesdays, of the controlled substance count sheets and the shift change record to assure that all medication personnel are identified for each shift by initials placed in the appropriate location. Review of the count sheets will verify both correct completion and count of medication on the record. Each review will be identified by the placement of initials and date in the margin beside each Wednesday entry on the form. All medication staff will receive follow up training on the Shenandoah Place Medication Administration Plan as well as review of proper procedures for the storage, counting and documentation of controlled medications.
Standard #:	22VAC40-73-860-I
Description:	Based upon direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are stored in a locked area. EVIDENCE: 1. During a walk through of the facility, the LI observed the housekeeping cart in the hallway unlocked and unattended that contained multiple bottles of cleaning supplies. 2. During a walk through of the facility, the LI observed the door to the beauty shop open and unattended. The counter contained a dispenser of disinfectant solution.
Plan of Correction:	Ongoing training and monitoring will occur at Shenandoah Place for proper storage of the housekeeping cart. The cart will be in direct sight and control of the person using at all times. While not in use, the cart will be maintained behind a locked door. Doors to rooms in which potentially hazardous chemicals are stored shall remain locked and inaccessible to persons other than SP staff.