VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shenandoah Valley Westminster-Canterbury
300 Westminster-Canterbury Drive
Winchester, VA 22603
(540) 665-0156

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Jan. 6, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Discussion occurred on the following topics: 1) Ensure all insulin orders include parameters; review of orders for resident A. 2) Ensure all PRN orders consistently include directions as to what to do if symptoms persist. 3) Include acknowledgement on ISP indicating that resident has received a copy. 4) Identify frequency of checks for residents as it pertains to ability to use call bell system. 5) Acknowledgement to include resident rights and orientation have been reviewed with resident and not just the legal representative. 6) Administrator to send current fire and health inspection to licensing inspector.

Comments:

An unannounced renewal inspection was conducted by two LIs on 01/06/2020. There were 54 residents in care. The activity calendar and lunch menu accurately reflected what the LIs observed. The facility was clean and free from any foul odors. Eight resident, one discharge, four staff and private sitter records were reviewed. The December 2019 medication administration records were reviewed for a selected number of residents. There was one repeat violation relating to medication administration. Details of non-compliance can be viewed in the violation notice section of this report. If you have any questions, please contact the licensing inspector at (540) 332-2300 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' records, the facility failed to ensure medications are administered in accordance with physician'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) The electronic medication administration record for resident A does not include the initials of evening shift direct care staff on 12/23/19 for feet elevation. 2) The electronic medication administration record for resident A does not include the initials of direct care staff on 12/07/19, 12/25/19 and 127/27 at 6:00am for application of compression stockings. a. There are no initials of direct care staff for removal of compression stockings on 12/23/19 at 9:00pm. 3) Resident A has duplicate orders for Clindamycin HCL 300mg. 4) The medication administration record for resident D indicates Methocarbamol was administered on 12/1/19 at 9:43pm, 12/02/19 at 10:32am and 12/03/19 at 10:21am. Instructions indicate to notify physician if medication is not effective within 24 hours. There is no documentation of physician notification. a. The electronic medication administration record indicates Methocarbamol was administered on 12/20/19 at 10:04am. Documented results indicate medication was ineffective. There is no documentation of follow-up. 5) The electronic medication administration record for resident D does not include the initials of evening direct care staff for Serotonin Syndrome monitoring on 12/09/19 and 12/27/19. a. There are no initials of night shift direct care staff for 12/09/19. 6) The electronic medication administration record indicates Miralax was administered to resident D on 12/06/19 at 10:08pm. Documented results indicate medication was ineffective. There is no documentation of follow-up. 7) The electronic medication administration record indicates Voltaren Gel was applied for shoulder pain to resident D on 12/05/19 at 9:16pm, 12/06/19 at 10:13am, 12/07/19 at 12:13pm, 12/08/19 at 10:01am, 10/09/19 at 9:21am and 12/10/19 at 9:36am. Instructions indicate to notify the physician within 24 hours if ineffective or symptoms persist. There is no documentation of physician notification. 8) The electronic medication administration record for resident D does not include the initials of direct care staff for administration of Remeron on 12/24/19 at 10:00pm. 9) The electronic medication administration record for resident D does not include the initials of direct care staff for administration of Tylenol with Codeine on 12/16/19 at 6:00am. 10) Resident E has the following order: Metoprolol Succinate ER 25mg: give 0.5 tablet by mouth in the morning for hypertension. Hold if systolic blood pressure is less than 100 and diastolic is less than 60. Hold for pulse less than 60. a. Documentation in the electronic medication administration record indicates resident's blood pressure was 98/58 on 12/27/19 at 8:00am and medication was administered. b. Clarification to be obtained on order: 0.5 tablet vs 0.5mg or 1/2 tablet. 11) The electronic medication administration record for resident F does not include the initials of direct care staff on 12/14/19 and 12/18/19 at 6:30am for administration of Levothyroxine. 12) Documentation in the electronic medication administration record for resident F indicates Acetaminophen was administered on 12/06/19 at 12:57pm with unknown results; 12/06/19 at 5:00pm and was ineffective; 12/07/19 at 5:52pm and was ineffective. Instructions indicate to notify the physician if ineffective within 24 hours. Due to the volume of documentation gathered during this inspection, information is included in a separate document and is available upon request.
Plan of Correction:	1. A review of the MAR for residents A, D, E & F as well as all other MAR?s was done to determine the potential impact on the residents. 2. Education for the staff, with one to one training for those specific Medication Aides/nurses, present during the dates of documentation violations, will be provided on proper medication administration protocols with return demonstrations to acknowledge understanding. 3. All regularly scheduled licensed nurses will be reeducated by the Nurse Educator, Assistant Director for Health Services and/or designee on appropriate follow up response and documentation on medication effectiveness. 4. Approximately 50% of residents will be audited monthly for six months, then 35% of residents quarterly for two quarters for effectiveness by Nurse Educator, Assistant Director for Health Services or designee. Thereafter, 25% of our residents will be randomly reviewed to ensure compliance. 5. Staff on duty during the audits will have medication administration procedures reviewed and subsequent issues addressed with corrective action as necessary. The plan will be completed by February 24, 2020.