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 20, 2024

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

N/A

Comments:

Type of inspection: ?Monitoring? Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/20/2024 8:40 am ? 3:30 pm; 6/21/2024 9:00 am ? 3:00 pm. 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: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 1 Observations by licensing inspector: Observed activities, lunch being served, building grounds, and medication pass. Additional Comments/Discussion: One collateral interview with a resident spouse. An exit meeting will be conducted to review the inspection findings. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: ?Yes?

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on record review and staff interview, the facility failed to ensure within four months of the start date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment. Evidence: 1. Staff 1 (date of hire 12/7/2023) record did not contain 10 hours of training in cognitive impairment within 4 months of hire. 2. Staff 2 (date of hire 11/1/2023) record did not contain 10 hours of training in cognitive impairment within 4 months of hire. 3. Staff 4 acknowledged that these trainings were not completed
Plan of Correction:	Beginning immediately, the administrator will make sure that all direct care staff receive at least 10 hours of training in cognitive impairment within 4 months of hire. This training will begin at hire and will continue with 2 hours of training per month on cognitive impairment, causes, behaviors and communication. The in-service will be done by the facility nurse/admin or an appropriate trainer for the condition at hand and documented in the staff record.
Standard #:	22VAC40-73-270-1
Description:	Based on record review and staff interview, the facility failed to ensure that direct care staff received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. Evidence: 1. Staff 1 (date of hire 12/7/2023) record did not contain documentation of aggressive resident training. 2. Staff 2 (date of hire 11/1/2023) record did not contain documentation of aggressive resident training. 3. Staff 4 acknowledged that these trainings were not completed.
Plan of Correction:	Aggressive training has been performed for current staff. The administrator will ensure that all staff receives aggressive training initially upon hire and will continue with multiple training courses on aggressive behavior throughout the year. Documentation of the training will be kept in the staff record.
Standard #:	22VAC40-73-280-B
Description:	Based on staff interview it was determined that the facility failed to maintain a written plan that specifies the number of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan shall be directly related to actual resident acuity levels and individualized care needs. Evidence: 1. The LI requested the written staffing plan, and it was not provided. 2. Staff 4 acknowledged the facility did not have a written plan.
Plan of Correction:	A staffing plan has been developed and put into place at Shenandoah Terrace. The plan is maintained with policies and procedures and specifies the number of direct care staff needed to meet any routine and special needs of residents at the facility.
Standard #:	22VAC40-73-290-A
Description:	Based on record review and staff interview, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. Staff schedule for June 2024 was requested and reviewed. Schedule did not include the person in charge for each shift, and the shift the administrator worked. 2. Staff 4 acknowledged the person in charge and administrator shift were not listed on the schedule.
Plan of Correction:	As of 6.24.2024, the employee in charge of each shift is indicated on the monthly schedule with an asterisk. The administrator?s schedule is listed on the employee schedule. The administrator will ensure this continues.
Standard #:	22VAC40-73-310-M
Description:	Based on record review and staff interview, the facility failed to have a written agreement between the assisted living facility and a hospice provider that met all criteria in the standards. Evidence: 1. LI requested and reviewed two hospice provider agreements with the facility. 2. A hospice agreement, signed 6/13/2024, did not include an acknowledgement that services provided shall be reflected on the individualized service plan (ISP). 3. Staff 4 acknowledged the hospice agreement did not include their services would be included in the resident ISP.
Plan of Correction:	Hospice has been contacted regarding the need to amend their contract to include acknowledgement that services provided by the hospice agency will be reflected on the ISP. Their contract will be amended as of 7/17/2024 and either faxed or delivered to the facility for signature by 7/23/2024. In the future, the administrator will ensure hospice agreements include that all services will be reflected on the facility?s ISP.
Standard #:	22VAC40-73-350-C
Description:	Based on record review and staff interview, the facility failed to ensure that each resident or his legal representative is fully informed upon admission and annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered, including how to obtain such information. Evidence: 1. LI requested documentation of notification of the sex offender registry. 2. Staff 4 acknowledged that the annual review with residents or their legal representative was not completed.
Plan of Correction:	Written documentation has been developed and reviewed with current residents or legal representatives regarding the sex offender registry, information contained therein and how to access said information. This information will be reviewed by the administrator with responsible parties and signed annually. Documentation of the review will be maintained in the client chart for review.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and staff interview, the facility failed to ensure individualized service plans (ISP) shall be reviewed and updated at least once every 12 months for one of the two resident records reviewed. Evidence: 1. During a building tour on 6/20/2024 licensing staff observed Resident 3 had bedrails installed on their bed. 2. Resident 3 (date of admission 5/13/2024) ISP dated 5/30/2024 did not include the use of bedrails. 3. Staff 4 acknowledged that the bed rails were not included in the ISP.
Plan of Correction:	The administrator will review all service plans at least every 12 months and as conditions warrant. Bedrails have been added to the plan for resident 3.
Standard #:	22VAC40-73-520-I
Description:	Based on observation and staff interview, the facility failed to ensure the activity on the posted schedule was provided. Evidence: 1. During a building tour on 6/20/2024 and 6/21/2024 licensing staff observed the activity at 10:00am did not match the observed resident activity at that time. 2. Staff 4 acknowledged the Activity calendar had not been updated. 3. Photo evidence of activity calendar.
Plan of Correction:	All activities performed will be listed on the activity calendar. Any variation of the activity schedule will be changed on the calendar.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and staff interview the facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident and properly stored at the facility. Evidence: 1. LI observed a med pass and reviewed the medication administration record (MAR). The LI observed prn medications listed on the MAR were missing from the medication cart. 2. Resident 4 had a physician order for prn Guaifenesin (order date 5/9/2023), prn Ketoconazole 2% shampoo (order date 7/20/2023), and prn oxygen (order date 12/8/2023) were not available. 3. Staff 2 acknowledged that the medications were not in the med cart oxygen was not in the resident room.
Plan of Correction:	PRN medications will be maintained in the med cart for all residents. The nightshift medication aide will be in charge of monitoring and ensuring that all resident?s PRN meds remain in date and in the cart for use.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and staff interview, the facility failed to ensure the criminal history record report (CHRR) was obtained on or prior to the 30th day of employment for each staff. EVIDENCE: 1. Staff 6 (date of hire 6/5/2023) contains a CHRR dated 12/8/2023. 2. Staff 7 (date of hire 7/6/2023) contains a CHRR dated 12/8/2023. 3. Staff 8 (date of hire 11/1/2023) contains a CHRR dated 12/8/2023. 4. Staff 9 (date of hire 4/8/2024) does not contain a CHRR. 5. Staff 10 (date of hire 8/14/2023) contains a CHRR dated 12/8/2023. 6. Staff 11 (date of hire 11/1/2023) contains a CHRR dated 12/15/2023). 7. Staff 4 acknowledged the CHRR records.
Plan of Correction:	Beginning immediately, CHRR will be obtained by Shenandoah Terrace through the VSP before employment or prior to an employee?s 30th day of employment with the facility. An online account has been established to ensure that CHRRs are obtained in a timely fashion. The CHRR will be obtained by the facility administrator and kept on file in the facility.