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: Jan. 17, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 2:00 pm on 1/17/2024 and exited at 3:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 1/17/2024 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 48 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon a review of records and interviews, conducting during a focused monitoring inspection on 1/17/2024, the facility failed to ensure their medication management plan was implemented correctly. Evidence: 1. Page 1 of the medication management plan states ?the implementation of the Shenandoah Senior Living (SSL) Medication Administration plan is to assure administration of appropriately prescribed medication to the correct resident.? 2. According to facility records, Staff 1 ?used another residents unopened Lantus Insulin pen on a resident (Resident 1) whom was out of his own prescription.? 3. According to interview with Collateral Contact 1 and 2 on 1/17/2024 at approximately 2:15 pm, Resident 1 was administered insulin from another resident?s insulin pen by Staff 1.
Plan of Correction:	The facility has and has kept current and implements a written plan for Medication Management. The facilities Medication Management has been reviewed and was approved by Licensing. Our Medication Management Plan addresses procedures for administering medication and ordering medications. The community had self- reported an incident to their LI, APS and The Virginia Board of Nursing regarding RMA in question. The RMA in question, under their own self-actions, failed to follow facility implemented Medication Management Plan and Policies and procedures of the facility. Executive Director, Resident Care Director and / or Memory Care Director will ensure that all community RMA?s follow the previously implemented Shenandoah Senior Living Medication Administration plan and facility policies and procedures to ensure administration of appropriately prescribed medications to the correct resident to ensure safe and appropriate medication management for each resident of the community. Executive Director, Resident Care Director and / or Memory Care Director will ensure that all facility registered medication aides have filled or refilled residents? prescription medications and/or over the counter medications by utilizing the implemented Pharmacy Log per company policy and procedure. Any RMA failing to follow facility policies, procedures and regulations will be subject to progressive disciplinary actions up to and including termination of employment and reporting to any required regulatory officials/entities. The Executive Director, Memory Care Director and/or appropriate designee, will review the pharmacy log daily in Memory Care and sign daily to acknowledge task completion. Executive Director, Resident Care Director and/or appropriate designee will review the pharmacy log daily in Assisted Living and sign daily to acknowledge task completion; and following the weekend on Monday, Executive Director, Resident Care Director and Memory Care Director and/or appropriate designee will review pharmacy logs to ensure task completion for Saturday and Sunday. RMA in question acted on her own behalf, under her own will, failed to report the need for refill prescription nor did they make the request to the resident in questions PCP. Failing to follow facility Policy and Procedure, Virginia Board of Nursing Guidelines and Department of Social Service regulations Once the facility became aware of incident, the facility completed and submitted report to LI, APS, and VA Board of Nursing. RMA in question was disciplined, removed from the medication carts, and reported to VA Board of Nursing. All RMA?s have been required to complete 4-hour medication aide refresher course. Certificates of 4 Hour Medication Aide Refresher will be kept on-site in each individual employee record.