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: May 24, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 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

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: 05/24/2023 from approximately 9:30am until 7:45pm. 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: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed:4 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 3 Observations by licensing inspector: postings, fire drills, menus, resident council, activities calendar, meals, pharmacy review, dietary review, staff interactions, health care oversight, first aid kits etc. Additional Comments/Discussion: A preliminary review of the violations was completed with the administrator at the end of the inspection. Opportunity was given to ask questions and to provide any additional information related to the violations. 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records, the facility failed to ensure an annual tuberculosis risk assessment documenting the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health of a form consistent with it. EVIDENCE: 1. The risk assessment form for staff #3 hired on 06/15/2021 was incomplete. 2. The risk assessment form for staff #4 hired on 06/16/2021 was incomplete.
Plan of Correction:	A) Residents affected- all. The clinic staff who complete the TB tests and assessments will reconcile at the end of each week who is still outstanding for the completion of this requirement. They will then email the respective department heads and our Administrator and DON who is out of compliance. B) Potential for residents to be affected- all. The clinic staff who complete the TB tests and assessments will reconcile at the end of each week who is still outstanding for the completion of this requirement. They will then email the respective department heads and our Administrator and DON who is out of compliance. C) Systems change- Our clinic nurse will also attend Education Day each month to get the TB assessments completed with the employees that attend for their annual work anniversary that corresponds with the TB assessment due that same month. D) Monitoring- the above stated weekly reconciliation with a notification email sent to Department heads, the administrator and our DON. E) Date of completion- 6/30/2023.
Standard #:	22VAC40-73-380-A
Description:	Based on review of residents? records the facility failed to ensure prior to or at the time of admission, the required personal and social data information was obtained. EVIDENCE: 1. The records for residents #2, #3, #4, #5, #6, #7, and #8 did not contain information regarding previous mental health or intellectual disability services history, if any, and if applicable for care or services. 2. The records for residents #2, #3, #4, #5, #6, #7 and #8 did not contain information regarding current behavioral and social functioning, strengths, and problems. 3. The records for residents #2, #3, #4, #5, #6, #7 and #8 did not contain information regarding substance abuse history if applicable for care or services.
Plan of Correction:	A) Residents affected- 2,3,4,5,6 and 7. Now have social data sheets (DSS model forms) in their charts. The data forms now address all mental health and intellectual disabilities history and any applicable care for these needs. The data forms also address current behavior and social functioning strengths and problems. The data forms also reflect any substance abuse history and applicable care or services. B) Potential for all residents to be affected- A complete audit will be done so each resident has a social data sheet in their chart to address the above stated conditions. C) Systems Change- all residents upon admission to Assisted Living will have the social data form completed. D) Monitoring. Periodic audits will be performed to make sure all residents have social data forms in their charts. E) Date to be completed- 6/30/2023.
Standard #:	22VAC40-73-410-A
Description:	A) Residents affected- 4 and 5 residents now have resident orientation forms in their charts. B) Potential for all residents to be affected- a complete audit will be conducted to ensure all orientation forms are in each resident?s chart. C) Systems change- a second check of the resident?s chart to ensure the orientation form is complete will take place at the time of admission. D) Monitoring a periodic audit of residents? charts to ensure the orientation forms are present. E) Date to be completed- 6/30/2023.
Plan of Correction:	A) Residents affected- 4 and 5 residents now have resident orientation forms in their charts. B) Potential for all residents to be affected- a complete audit will be conducted to ensure all orientation forms are in each resident?s chart. C) Systems change- a second check of the resident?s chart to ensure the orientation form is complete will take place at the time of admission. D) Monitoring a periodic audit of residents? charts to ensure the orientation forms are present. E) Date to be completed- 6/30/2023.
Standard #:	22VAC40-73-450-C
Description:	Based on review of residents? records, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) contained all assessed needs. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident #2, dated 12/11/2022 indicates resident requires physical assistance with dressing. This is not indicated on the ISP dated 12/11/2022. 2. The Uniform Assessment Instrument for resident #6 dated 05/04/2023 indicates mechanical assistance is needed with walking. The type of mechanical support is not identified on the ISP dated 05/04/2023.
Plan of Correction:	A) Residents affected- 2 and 6 their ISPs have been updated to reflect the specific needs regarding dressing assistance for resident 2. For resident 6 the Isp now reflects the specific mechanical help required for walking. B) Potential for all residents to be affected- All ISPs will be audited to ensure the specific types of assistance required will be documented. C) Systems Change- upon completion of the comprehensive ISP the nurse will specify the exact type of assistance required with each ADL task. D) Monitoring- Monthly audits will be conducted to ensure all ISPs have specific assistance types noted. E) Date of Completion 6/30/2023.
Standard #:	22VAC40-73-490-B
Description:	Based on document review, the facility failed to ensure the health care professional provided health care oversight for the required components and recommendations for change as needed. EVIDENCE: A review of the on-site health care oversite completed on 03-31-2023 did not include the date oversight was provided, signature of the licensed health care professional(s) and recommendations for change for the following: Monitor conformance to the facility?s medication management plan and the maintenance of required medication reference materials; Evaluate the ability of residents who self-administer medications to continue to safely do so; Observe infection control measures and consistency with the infection control program of the facility.
Plan of Correction:	A) Residents affected-all. Staff reeducation to complete and sign off on all areas of the healthcare oversight process to include medication management guidelines. B) Potential for residents to be affected-all. Staff reeducation to complete and sign off on all areas of the healthcare oversight process to include medication management guidelines. C) Systems change- Our Director of nursing will ensure complete compliance on the day the Healthcare oversight is completed. D) Monitoring- quarterly compliance audit will be conducted. E) Date of completion- 6/30/2023.
Standard #:	22VAC40-73-680-I
Description:	Based on review of resident?s Medication Administration Record (MAR), the facility failed to ensure the MAR included all required information. EVIDENCE: 1. Resident 9 has the following order: Tramadol HCL Oral tablet 50mg: Give one tablet by mouth every 6 hours as needed for severe pain. 2. Documentation in the MAR indicates medication was administered on 05/16/2023 at 6:02am and was not effective. There is no documentation of follow-up. 3. Documentation in the MAR indicates medication was administered on 05/20/2023 at 8:40am and was not effective. There is no documentation of follow-up.
Plan of Correction:	A) Resident affected- #9, reeducation of staff to follow up with investigation and proper documentation showing further treatment both pharmacological and non-pharmacological interventions. B) Potential for residents to be affected- any resident on pain medications. Reeducation of staff to follow up with investigation and proper documentation showing further treatment both pharmacological and non-pharmacological interventions. C) Systems Change- Staff reeducation, periodic spot checking for compliance by the Assisted Living care coordinator for compliance. Reeducation to include interventions to be discussed during report at change of shift. D) Monitor- spot audits weekly. E) Date of completion 6/30/2023.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure cleaning supplies and other hazardous materials are in a locked area. EVIDENCE: During a walk-though of the third floor, the LI observed the mechanical room door propped open and unattended. A shelf in the room contained multiple containers of cleaning supplies and chemicals.
Plan of Correction:	A) Residents affected- all. Facility Administrator reeducated the contracted employee to always keep closet doors shut and locked when not in them. Contracted employee agreed to do this. B) Potential for residents to be affected- all. Facility Administrator reeducated the contracted employee to always keep closet doors shut and locked when not in them. Contracted employee agreed to do this. C) Systems change- a memo will go out to all contracted companies educating their employees who come on site that all closets must be shut and locked when the contracted employee is not in that room even if they leave for just a few minutes. D) Monitoring- staff will remind contracted employees to keep doors shut and locked when not in use. Staff will periodically test doors on their floor to ensure compliance. E) Date of completion- 6/30/2023.
Standard #:	22VAC40-73-950-E
Description:	Based on document review and an interview, the facility failed to ensure a semi-annual review on the emergency preparedness and response plan was completed for all staff, residents, and volunteers. EVIDENCE: 1. There was no documentation indicating a semi-annual review of the emergency preparedness and response plan had been completed with staff, residents, and volunteers. 2. The LI interviewed the administrator on 05/24/2023 who confirmed a review a had not been completed and was unable to confirm the date of the previous review.
Plan of Correction:	A) Residents/Staff affected- all. Schedule to educate on our emergency preparedness plan has been put into place. B) Potential for residents/staff to be affected- all. Schedule to educate on our emergency preparedness plan has been put into place. C) Systems Change- residents will be educated twice a year during their scheduled resident council meetings. They will sign in confirmation they received this education. Staff will receive training twice a year on their annual education day as well as a subsequent staff town hall which we have quarterly. Sign in sheets will be utilized. We currently do not use volunteers in Assisted Living. D) Monitoring- periodic audits to make sure the sign in sheets reflect 100% compliance with this requirement. E) Date of completion- 6/30/2023.
Standard #:	22VAC40-73-970-A
Description:	Based on document review, the facility failed to ensure fire and emergency evacuation drill frequency and participation are in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. EVIDENCE: 1. Documentation of fire drills indicate a fire drill was conducted on 02/28/2023 at 11:06pm; 03/29/2023 at 11:35pm and 04/27/2023 at 9:45pm. 2. Documentation of a day shift fire drill is 12/30/2022 at 1:54pm.
Plan of Correction:	A) Residents affected- all. The Life safety manager will ensure there is a fire drill on each 8-hour shift and will conduct the drills at different times on each shift. B) Potential for residents to be affected- all. The Life safety manager will ensure there is a fire drill on each 8-hour shift and will conduct the drills at different times on each shift. C) Systems change- A calendar of fire drills will be scheduled each quarter to reflect occurrence on each shift and at different times on those shifts. D) Administrator to review monthly for adherence to this schedule. E) Date of completion 6/30/2023.
Standard #:	22VAC40-90-40-B
Description:	Based on review of staff records and an interview, the facility failed to ensure a criminal history record report was obtained on or prior to the 30th day of employment. EVIDENCE: 1. The file for staff #19, hired on 06/14/2022, did not contain a criminal history record report. 2. The LI interviewed the administrator who stated ?the criminal history report could not be located for staff #19.?
Plan of Correction:	A) Residents affected- all. The HR director will ensure all VSP background checks are fully completed monthly. B) Potential for residents to be affected- all. The HR director will ensure all VSP background checks are fully completed monthly. C) Systems change- HR generalist will make sure all VSP background checks are completed and stored in the employee?s file. HR Director to audit monthly. D) Monthly audit by HR Director. E) Date of completion- 6/30/2023.