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: Sept. 5, 2023

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness Mixed Population Safe, Secure Environment

Comments:

Date of Inspection: September 5, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 41 Number of records reviewed and interviews conducted- 10 records (staff and residents), 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: resident council reports, dietician report, pharmacy review, fire drills and healthcare oversight. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have a coordinated plan of care for residents receiving hospice services as required. Evidence: Resident A and D have no documentation to reflect a coordinated plan of care between the facility and the hospice agency.
Plan of Correction:	The ISPs were corrected at the time of inspection. All ISPs will reflect a coordinated plan of care between the facility and hospice agencies for residents in care as required. The Administrator will conduct random audits to ensure compliance.