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: June 12, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Number of resident records reviewed: 1 Number of staff records reviewed: 1 An exit meeting will be conducted to review the inspection findings. 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 via email from the facility on 06/01/2023 and an interview on 06/5/2023, 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 outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Communication via email on 05/27/2023 indicates Resident #1 was given an extra dose of morphine 15mg at 12:30am on 05/27/2023. The facility ?incident/accident? report dated 05/27/2023 at 12:30am indicates resident #1 was administered morphine at the wrong time by staff #1. 2. Resident #1 has the following order: Morphine Sulfate 15mg tablet: Take one by mouth every 12 hours. 3. The Medication Administration Record (MAR) indicates medication was administered at 10:00pm. 4. 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. 5. The LI interviewed staff #1 on 06/05/23 who confirmed resident #1 was administered morphine 15mg at 10:00pm and again at 12:30am on 05/27/2023.
Plan of Correction:	Intensive Plan of Correction Required