VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shenandoah Terrace
447 W. Old Cross Road
New market, VA 22844
(540) 740-8600

Current Inspector: Jill James (540) 418-2631

Inspection Date: April 27, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Please send re-inspection by Fire Marshal to your licensing inspector once repair/cleaning of kitchen hood has been completed.

Comments:

Type of inspection: Renewal Date(s) of inspection the licensing inspector was on-site at the facility for each day of the inspection: 04/27/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 17 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Postings, fire drills, activity calendar, menus, medication review, dietary oversight. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1100-A
Description:	Based on a review of residents? records, the facility failed to obtain written approval from a guardian or legal representative prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment. EVIDENCE: Resident #2 was admitted to safe secure environment on 09/09/2022. The ?Approval for Placement in a Special Care Unit? form dated 09/09/2022 is not signed by the guardian or legal representative for the resident.
Plan of Correction:	The facility will ensure that no resident is admitted into the secure unit without approval for placement forms being completed by the client's representative and on the chart. Review has been performed with the facility manager and the approval in question will be presented to the representative and signed by May 8, 2023.
Standard #:	22VAC40-73-1110-B
Description:	Based on review of residents? records, the facility failed to perform a six month review after placement of a resident in the safe, secure environment. EVIDENCE: 1. Resident #2 was admitted to the safe, secure environment on 09/09/2022. There is no documentation of a six-month review of appropriateness of continued residence in the special care unit on file. 2. Resident #3 was admitted to the safe, secure environment on 07/14/2022. There is no documentation of a six-month review of appropriateness of continued residence in the special care unit on file. 3. Resident #5 was admitted to the safe, secure environment on 06/30/2022. There is no documentation of a six-month review of appropriateness of continued residence in the special care unit on file.
Plan of Correction:	The facility will ensure that reviews of appropriateness of placement will be performed 6 months after the admission review for all residents. A review was performed with the facility manager and the reviews in question will be performed and on the chart by May 8, 2023.
Standard #:	22VAC40-73-250-C
Description:	Based on review of staff records, the facility failed to ensure staff files contained all required documentation. EVIDENCE: 1. The files for staff #1, #2, #3, #4 and 5 did not contain name and telephone number of person to contact in an emergency. 2. The files for staff #1, #2, and #4 did not contain a job description. 3. The files for staff #5 did not contain a current job description. 4. The file for staff #4 did not contain a record of initial staff training and orientation. 5. The files for staff #2, #3 and #5 contained incomplete records or initial staff training and orientation.
Plan of Correction:	The facility will ensure the required information will be maintained within employees charts within the timeframes allotted. A review was performed with the facility manager and all charts will contain information that has been identified as missing by May 8, 2023.
Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records, the facility failed to ensure staff submitted results of a tuberculosis risk assessment, documenting the absence of absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. EVIDENCE: 1.The file for staff #2 hired on 12/19/2022 did not contain documentation of a tuberculosis assessment. 2. The file for staff #3 hired on 11/16/2022 did not contain documentation of a tuberculosis assessment. 3. Documentation of tuberculosis testing for staff #1 hired 02/09/2023 is dated 12/22/2022.
Plan of Correction:	Tuberculosis tests/screens will be performed on or within seven days prior to the first day of employment at Shenandoah Terrace for all employees. Review performed with facility manager, current TB tests/screens will be obtained for all employees without by May 8, 2023.
Standard #:	22VAC40-73-260-A
Description:	Based on review of staff records, the facility failed to ensure each direct care staff member obtained certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff #4 hired on 01/23/2023 does not contain documentation of current certification in first aid. 2. The record for staff #5 hired on 11/08/2022 does not contain documentation of current certification in first aid.
Plan of Correction:	The facility will ensure that employees that need first aid will be scheduled for First Aid classes within two weeks of employment. All employee charts will be reviewed monthly to determine upcoming needs for CPR/First Aid training and the master chart of due dates will be updated monthly. Review performed with facility manager.
Standard #:	22VAC40-73-380-A
Description:	Based on review of residents? records, the facility failed to ensure all required personal and social information on a resident was obtained. EVIDENCE: The ?Resident/Personal Social Data Sheet? was incomplete for residents #1, #2, #3 and #4.
Plan of Correction:	Personal and social data will be on every resident's chart and complete as per regulation. Review has been performed with the facility manager and those charts in which the personal/social data forms are not complete will be finished by May 8, 2023.
Standard #:	22VAC40-73-550-G
Description:	Based on review of staff records, the facility failed to ensure an acknowledgment of a review of the rights and responsibilities of residents in assisted living facilities in filed in the staff person?s record. EVIDENCE: 1.The record for staff #2 hired 12/19/2022 did not contain an acknowledgment of review of resident rights and responsibilities. 2. The record for staff #4 hired 01/23/2023 did not contain an acknowledgment of review of resident rights and responsibilities. 3.The record for staff #5 hired 11/08/2022 did not contain an acknowledgment of review of resident rights and responsibilities.
Plan of Correction:	All employees will review and sign Resident Rights at the time of employment with the facility. This document will be reviewed and signed by the employee yearly and this documentation will be maintained in the employee file. Review performed with the facility manager, identified needs in current charts will be obtained by May 8, 2023.
Standard #:	22VAC40-73-970-A
Description:	Based on review on document review, the facility failed to ensure fire and emergency evacuation drill frequency and participation are in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13 VAC 5-51). EVIDENCE: 1. The ?Record of Required Fire and Emergency Evacuation Drills? shows there were no fire drills conducted in the months of September 2022, October 2022, November 2022 and January 2023. 2. On 04/27/2023, the LI interviewed staff # #7 and #8 who confirmed there is no documentation of fire drills being conducted in the months of September 2022, October 2022, November 2022 and January 2023.
Plan of Correction:	Monthly fire drills will be performed and documented as required. Review was performed with the facility manager, May's fire drill will be performed on the appropriate shift by May 8, 2023, future drills will be performed on each shift and appropriately documented. Requirements reviewed with facility manager.
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 file for staff #1 hired on 02/09/2023 did not contain a criminal history report. ` 2. The file for staff # 2 hired on 12/19/2022 did not contain a criminal history report. 3. The file for staff #3 hired on 11/16/2022 did not contain a criminal history report. 4. The file for staff #4 hired on 01/23/2023 did not contain a criminal history report. 5. The file for staff #5 hired on 11/08/2022 did not contain a criminal history report. 6. The file for staff #6 hired on 12/22/2022 did not contain a criminal history report.
Plan of Correction:	The facility will ensure that criminal history checks will be obtained for all new employees prior to their first day of employment at the facility. Review performed with the facility manager; all current employees will have criminal background checks performed by May 5, 2023.