VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shenandoah Senior Living
103 Lee Burke Road
Front royal, VA 22630
(540) 635-7923

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: June 15, 2023

Complaint Related: Yes

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Personnel, Resident Care and Related Services, Buildings and Grounds and Criminal History Records. Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: All required postings, staff and resident interactions, activities, lunch meal. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-250-C
Complaint related:	No
Description:	Based on a review of staff records, the facility failed to ensure the filed included all required components. EVIDENCE: 1. The filed for staff #2, hired on 12/05/2022 did not contain verification that the staff person has received a copy of his current job description. 2. The file for staff #3, 12/05/2022 did not contain verification that the staff person has received a copy of his current job description. 3. The file for staff 4, hired on 05/23/2023 did not contain verification that the staff person has received a copy of his current job description.
Plan of Correction:	Executive Director, Resident Services Director and Business Office Manager will ensure that Personal and Social data will be maintained on all staff to include Verification that the staff person has received a copy of their Job Description. A signed Job Description has been obtained and is on file for the employees noted on inspection. All other employee files will be audited by 7/1/23 to ensure that all required documents are on record for all employees by the Executive Director, Resident Services Director, and Business Office Manager. Moving forward, the Business Office Manager will set up all newly hired employee files and then either the Executive Director or the Resident Services Director will audit the file to ensure all required documents are on file for each newly hired employee to monitor for and maintain compliance.
Standard #:	22VAC40-73-560-F
Complaint related:	No
Description:	Based on direct observation, the facility failed to ensure all records are treated confidentially and that information shall be made only when needed for care of the resident. EVIDENCE: During a walk-through of the facility, the LI observed the resident shower book, ADL book and Daily Communication Log on a table in the dining room unattended.
Plan of Correction:	The Executive Director/Resident Services Director and/or Designee (Designated Person in Charge) will ensure that all records are treated confidentially, and that information shall be made only available when needed for the care of the resident. All records will be made available for inspection as requested by the Licensing Inspector. A Mandatory Meeting was held on 6/20/23 and all care staff were reminded that all resident care binders are to be secured in the medication room or other designated secured area when they are not completing documentation nor are they to be left unattended or out of eyesight when not completing documentation. Executive Director, Resident Services Director and/or Designee (Designated Person in Charge) will ensure that the care Binders will be secured after each use in the medication room or other designated secured area. Executive Director, Resident Services Director and/or Designee will complete spot checks to monitor for compliance at various times of the day. All RMA?s will document at the end of each shift that all care logs are secured in the medication room or other designated secured area at the end of their shift.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on review of resident records, the facility failed to ensure documentation of rounds made every hour include the date and time of the rounds and the staff member who made the rounds. EVIDENCE: 1. The round sheet for resident #5 did not include name or initials of staff member who made hourly rounds on 06/11/2023 for 7:00am through 2:00pm 2. The round sheet for resident #6 did not include the name or initials of staff member who made hourly rounds on 06/05/2023 for 4:00pm through 10:00pm. 3. The round sheet for resident #7 did not include the name or initials of staff member who made hourly rounds on 06/09/2023-6/10/2023 for 12:00am through 5:00am. 4. The round sheet for resident #8 did not include the name or initials of staff member who made hourly rounds on 06/07/2023 for 5:00pm through 10:00pm. 5. The round sheet for resident #9 did not include the name or initials of staff member who made hourly rounds on 06/05/2023 for 4:00pm through 10:00pm; 06/08/2023-06/09/2023 for 11:00pm through 6:00am. 6. The round sheet for resident #10 did not include the name or initials of staff member who made hourly rounds on 06/05/2023 for 8:00pm through 10:00pm. 7. The round sheet for resident #11 did not include the name or initials of staff member who made hourly rounds on 06/11/2023 for 7:00am through 2:00pm. 8. The round sheet for resident #12 did not include the name or initials of staff member who made hourly rounds on 06/08/2023-06/09/2023 for 11:00pm through 6:00am; 06/09/2023 for 7:00am through 3:00pm; 06/10/2023 for 04:00pm through 6:00pm; 06/11/2023 for 7:00am though 2:00pm; 06/13/2023 for 2:00pm-3:00pm. 9. The round sheet for resident #13 did not include the name or initials of staff member who made hourly rounds on 06/08/2023-06/09/2023 for 11:00pm through 6:00am; 06/09/2023 for 7:00am through 3:00pm; 06/10/2023 for 04:00pm through 6:00pm; 06/11/2023 for 7:00am though 2:00pm; 06/13/2023 for 2:00pm-3:00pm. 10. The round sheet for resident #14 did not include the name or initials of staff member who made hourly rounds on 06/08/2023-06/09/2023 for 11:00pm through 6:00am; 06/09/2023 for 7:00am through 3:00pm; 06/10/2023 for 04:00pm through 6:00pm. 11. The round sheet for resident #15 did not include the name or initials of staff member who made hourly rounds on 06/09/2023 for 7:00am through 3:00pm; 06/10/2023 for 04:00pm through 6:00pm; 06/11/2023 for 7:00am though 2:00pm; 06/13/2023 for 2:00pm-3:00pm.
Plan of Correction:	The Executive Director, Resident Services Director, Memory Care Director and /or Designee (Designated Person in Charge) shall ensure that documentation of rounds are made as needed and a notation will be made on each individual residents Round Form that includes the residents Name, the date and time of the rounds, and the staff member who completed the rounds and the documents will be retained for a period of two years. All Care staff attended a Mandatory Inservice on 6/20/2023 and this regulation was reviewed with all care staff at that meeting. Failure of any care staff member to complete any regulatory task or failure to follow community policies and procedures will result in progressive disciplinary actions for any employee that fails to follow stated regulatory guidelines or community policies and procedures. All current Care Staff will be trained in an additional inservice by 7/18/23 on the purpose of completing and how to document on the Rounds Form and any newly hired care staff will be trained upon Orientation utilizing the community rounds form, documentation will be retained in each employee?s file. Executive Director, Resident Services Director, and the Memory Care Director, will review round forms daily for the prior day and initial each round form to aide and monitor for regulatory compliance.
Standard #:	22VAC40-90-40-B
Complaint related:	No
Description:	Based on a review of staff records and an interview, the facility failed to ensure a criminal history report was obtained on or prior to the 30th day of employment. EVIDENCE: 1. The record for staff #5, hired on 04/24/2023 did not contain a criminal history report. 2. The LI interviewed staff #6 who confirmed a criminal history report had not been obtained for staff #5.
Plan of Correction:	The Executive Director, and/or appropriate designee will ensure completion of a criminal history record will be completed on all employees upon hire and will be obtained prior to the 30th day of employment. All employee files have been audited as of 6/19/23 and all required Criminal History records are all file for each employee employed at the community. The Executive Director and/or appropriate designee will utilize an employee tickler system moving forward to aide and monitor for regulatory compliance with this standard. The community utilizes the Virginia State Police system. The employee in question is no longer employed with the community.