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: May 22, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 05/20/2023 regarding allegations in the area(s) of: Resident care related to medication administration. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on communication received from the facility via email on 05/20/2023 and an interview on 06/05/2023, the facility failed to ensure medications are administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The ?Facility Incident/Accident Report dated 05/19/2023 at 12:00pm indicates resident #1 received another resident?s Oxycodone 5/325 by staff #1. 2. The rights of medication administration outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing on page 25 #6 are as follows: 1. Right Client; 2. Right Medication; 3. Right Dose; 4. Right Route; 5. Right Time; 6. Right Documentation. 3. The LI interviewed staff #2 on 06/06/2023 who confirmed staff #1 administered Oxycodone 5/325 to resident #1.
Plan of Correction:	The medication aide was counselled, and the error was discussed in detail with her. The administrator reviewed the rights of medication management. RIGHT Client, medication, Dose, route, time, documentation. Employee studied the current medication administration plan with this writer. Discussion ensued regarding distractions and the importance of staying focused. In addition to counsel, the RMA will complete a medication refresher course by 06/15/2023. Any further medications errors within 3 months of this incident will result in a report directly to the Board of Nursing.
Standard #:	22VAC40-90-40-B
Description:	Based on review of staff records, the facility failed to ensure criminal history reports are obtained on all staff within 30 days of hire. EVIDENCE: 1. The criminal history report for staff #1, hired on 03/02/2023 is dated 05/19/2023.
Plan of Correction:	Criminal history report for staff #1 was re-submitted for completed on 06/30/2023. Administrator will call Virginia State Police to obtain criminal history report ASAP. Future criminal history reports for new employees will be sent in a timely manner as required by DSS regulations.