Virginia DSS · Assisted Living Facility

Shenandoah Place, Inc.

📍 50 Burkholder Lane, New Market, VA, 22844

ID 32972One Year licenseActive
16
Inspections
On record
14
With violations
Visits that cited something
2
Clean visits
Nothing cited
45
Violations cited
Individual findings
30
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Shenandoah Place, Inc. was inspected 16 times between February 16, 2021 and August 4, 2025 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 45 violations under 30 distinct standards. 3 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 13 of these 16 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
08/31/2026
Administrator
Kelli Bailey
Licensing inspector
Margaret Woods-Kane
Inspector phone
(804) 724-9618
Approved for
Assisted Living · Non-Ambulatory

Inspection History

16

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

August 4, 2025Complaint survey4 violations
Inspection dates
08/04/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 Complaint Investigation
Comments
Type of inspection: ¿Complaint¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: August 4, 2025, from 2:00 p.m. to 3:11 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/13/2025 regarding allegations in the area of: RESIDENT CARE AND RELATED SERVICE. Number of residents present at the facility at the beginning of the inspection: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents in their rooms, at meal and activity. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jill James, Licensing Inspector at (540) 418-2631 or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on a record review and staff interview, the facility failed to ensure that a Uniform Assessment Instrument (UAI) was completed on an annual basis.
Evidence
  1. Record for resident 1 (admission 6/25/2024) was reviewed. A UAI from 6/24/2024 was in the record.
  2. Staff 1 acknowledged that the UAI reassessment had not been updated since 6/24/2024.
Plan of correction
CORRECTION – Facility will ensure that a Uniform Assessment Instrument will be completed as needed and yearly.
22VAC40-73-550-G
Based on a record review and staff interview, the facility failed to ensure a review of resident rights was completed annually.
Evidence
  1. Record for resident 1 (admission 6/25/2024) was reviewed. The last review of annual rights was documented on 6/25/2024.
  2. Staff 1 acknowledged that resident rights had not been reviewed annually.
Plan of correction
CORRECTION – The facility will review Resident Rights with all residents annually.
22VAC40-73-450-F
Based on a record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was updated every 12 months.
Evidence
  1. Record for resident 1 (admission 6/25/2024) was reviewed. An ISP from 6/24/2024 was in the record.
  2. Staff 1 acknowledged that the ISP had not been completed annually since 6/25/2024.
Plan of correction
CORRECTION – The facility will update Individualized Service Plan’s annually and as needed on each resident.
22VAC40-73-320-B
Based on a record review and staff interview, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed on an annual basis.
Evidence
  1. Record for resident 1 (admission 6/25/2024) was reviewed. A TB screening from 6/20/2024 was in the record.
  2. Staff 1 acknowledged that the TB screening had not been completed on an annual basis.
Plan of correction
CORRECTION - Facility will ensure that a risk assessment for Tuberculosis (TB Test) is completed before every admission and annually.
August 4, 2025Inspection5 violations
Inspection dates
08/04/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:August 4, 2025, from 9:15 a.m. to 4:00 p.m. 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: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:2 Number of staff records reviewed:3 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 5 Observations by licensing inspector: The Licensing Inspector observed staff engaged with the residents during activities, meals and medication administration. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare and medication oversight, Fire Inspection and Virginia Department of Health inspections. Liability insurance was verified. 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 abut the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jill James, Licensing Inspector at (540)418-2631 or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-950-E
Based on staff interview, the facility failed to implement a semi-annual review of the emergency preparedness plan with all staff and residents.
Evidence
  1. On 8/4/2025, the Licensing inspector requested documentation of the staff and residents review of the emergency preparedness and response plan.
  2. On 8/4/2025, staff 1 stated they were hired in December 2024 and that they had not implemented a review with staff and residents, nor could previous documentation be found.
Plan of correction
CORRECTION: This Administrator went over the emergency preparedness plan the 2nd week of August with all staff and residents and will continue to review every six months and upon hiring new staff or admitting new residents.
22VAC40-73-990-B
Based on staff interview, the facility failed to ensure that practice exercises on procedures for resident emergencies were practiced every six months by all staff on each shift.
Evidence
  1. On 8/4/2025, the Licensing inspector requested documentation of practice exercises on procedures for resident emergencies.
  2. On 8/4/2025, staff 1 stated there was no documentation on record, and that staff had not practiced exercises on procedures for resident emergencies. This violation is repeated from a 10/2/2024 inspection.
Plan of correction
CORRECTION: This Administrator will ensure that my staff practices the exercises for resident emergencies at least every six months. We did a practice exercise the 2nd week of August.
22VAC40-73-950-F
Based on staff interview, the facility failed to ensure an annual review of the emergency preparedness plan.
Evidence
  1. On 8/4/2025, the Licensing inspector requested documentation of the facility review of emergency preparedness plan.
  2. On 8/4/2025, staff 1 stated they were hired in December 2024 and that they had not documented a review of the emergency preparedness plan.
Plan of correction
CORRECTION: This Administrator reviewed the emergency preparedness plan the 2nd week of August after being cited and will continue to review the plan annually.
22VAC40-73-410-A
Based on record review and staff interview, the facility failed to document acknowledgement of orientation for new residents including emergency response procedures, mealtimes, and use of the call system.
Evidence
  1. Licensing Inspector (LI) reviewed resident 2’s record (admission 3/28/2025) and noted it did not include the required acknowledgement of orientation for new residents including emergency response procedures, mealtimes, and use of the call system.
  2. On 8/4/2025, staff 1 acknowledged that there was no documentation of the required orientation for new residents in the record for resident 2.
Plan of correction
CORRECTION: This Administrator will make sure that each new resident has been oriented on all emergency procedures as well as mealtimes and how the call bell system works using the lanyard call bell provided upon admission.
22VAC40-73-310-D
Based on record review and staff interview, the facility failed to ensure the administrator had provided written assurance to the resident the facility had the appropriate license to meet the resident’s care needs at the time of admission.
Evidence
  1. Review for resident 2’s record (application for admission 2/27/2025), by Licensing Inspector on (date) did not contain a copy of the required written assurance. On 8/4/2025, staff 1 acknowledged that the record for resident 2 did not include a copy of the required written assurance.
Plan of correction
CORRECTION: This Administrator shall provide each new resident with a letter of written assurance stating that the facility has the correct license to meet the new residents needs when admitting.
October 3, 2024Inspection1 violation
Inspection dates
10/03/2024
Areas reviewed
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: 10/3/2024 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed residents participating in activity programs and eating lunch. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on self-reported incident and resident records review, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. LI received self-reported incident that Res 1 had been administered another resident’s medications.
  2. Facility form, titled Medication Error Report’ states the following medication were administered to Resident 1 that were prescribed to another resident at the facility: Atenolol 25mg, Metformin 500mg, Omeprazole 20mg, Preservision ARED eye vitamin tablet, and Rosuvastatin 10mg.
Plan of correction
Resident room numbers and names will be displayed on or at the doorway to facilitate accurate identification of Resident while administering medications.
October 2, 2024Inspection7 violations
Inspection dates
10/02/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/2/2024-10/3/2024 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed residents eating breakfast and lunch and participating in activity programs. Additional Comments/Discussion: 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-990-B
Based on staff interview, the facility failed to review procedures regarding resident emergencies at least every six months with all staff.
Evidence
  1. Staff 3 stated a resident emergencies review had not been completed.
Plan of correction
Resident Emergency Practice Exercise will be conducted every 6 months.
22VAC40-73-620-A
Based on record review, the facility failed to have oversight at least every six months of special diets by a dietician or nutritionist for each resident who has such a diet.
Evidence
  1. The last oversite of special diets was completed on 11/22/2023.
Plan of correction
There shall be oversight at least every 6 months of special diets by a dietician or nutritionist for each resident who has a special diet ordered.
22VAC40-73-290-B
Based on observation and staff interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for I this chapter, in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. LI observed on the first day of inspection, on 10/2/2024, that Staff 5’s name was posted as the Person-in-Charge, but Staff 5 was not currently in the building at the time.
  2. Staff 4 stated she was the Person-in-Charge.
Plan of correction
Name plates created for each designated and fully trained person in charge will be displayed on each shift. Name tags are made and accessible to all staff.
22VAC40-73-450-C
Based on resident record review, the facility failed to describe the identified needs and date identified upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological behavioral, and emotional functioning, if appropriate; and (vi) other sources.
Evidence
  1. Resident 1 was assessed using the Uniform Assessment Instrument (UAI) on 3/19/2024 as needing Mechanical Help and Physical Help, these needs were not described as needs on the Individualized Service Plan (ISP) developed on 4/3/2024; the UAI dated 3/19/2024 assessed the resident as needing Mechanical Help and Physical Help and the ISP developed 4/3/2024 states the resident needs no human help to transfer; UAI dated 3/19/2024 assessed the resident as needing Mechanical Help and Physical Help and the ISP developed on 4/3/2024 states the resident needs no human help to walk; the UAI dated 3/19/2024 assessed the resident as needing Mechanical Help and Physical Help for Wheeling and ISP developed 4/3/2024 does not address the need for Wheeling assistance.
  2. Resident 1 had an order for PT/OT to Evaluate and Treat written on 9/8/2024. The ISP did not include information regarding Resident 1 receiving Home Health therapy services.
  3. Resident 2 was assessed using the UAI on 6/20/2024 as needing Mechanical Help and Physical Help to dress and the ISP developed on 6/25/2024 does not address Dressing assistance needed; the UAI assessed the resident on 6/20/2024 as needing assistance with eating and the ISP developed on 6/24/2024 does not address the need for assistance with eating.
  4. Resident 2 had a Fall Risk Assessment completed on 6/24/2024 which assessed the resident at a score of 20. According to the assessment tool, a score greater than 10 is considered at High Risk for potential falls. The ISP developed 6/25/2024 did not address the resident being at High Risk for potential falls
Plan of correction
Current review of al ISP's and UAI's to assure they match.
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents and volunteers with an emphasis placed on an individual’s respective responsibilities.
Evidence
  1. Based on record review and staff interview, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents and volunteers with an emphasis placed on an individual’s respective responsibilities. Evidence: Emergency Preparedness Review with staff supplied to LI was last completed on 3/13/2024.
Plan of correction
The Emergency Plan will be reviewed at Orientation for all new staff, and twice yearly in October and May. Documentation of review will be placed in the inservice training book after each review/training.
22VAC40-90-40-B
Based on staff record review, the facility failed to obtain a criminal record report on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff 6, hired 2/29/2024, had a criminal background check received by the facility on 7/17/2024.
  2. Staff 7, hired 2/18/2024, had a criminal background check received by the facility on 4/16/2024.
  3. Staff 8, hired 1/18/2024, had a criminal background check received by the facility on 4/30/2024.
  4. Staff 9, hired 6/24/2024, had a criminal background check received by the facility on 8/29/2024.
  5. Staff 10, hired 7/25/2024, had a criminal background check received by the facility on 8/29/2024.
  6. Staff 11, hired on 6/21/2024, had a criminal background check received by the facility on 8/29/2024.
Plan of correction
When I-9 form is completed, Background check will be filled out and submitted.
22VAC40-73-190-C
Based on staff interview, the facility failed to, prior to being placed in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities.
Evidence
  1. Staff 3 stated that Staff 4, who was the Person-in-Charge on 10/2/2024, had not received training on duties and responsibilities of being the Person-in-Charge.
Plan of correction
Name plates created for each designated and fully trained person in charge will be displayed on each shift. Name tags are made and accessible to all staff.
August 30, 2023Inspection0 violations
Inspection dates
08/30/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed Population
Comments
Date of Inspection: August 30, 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 19 Number of records reviewed and interviews conducted- 6 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 meals and activities. The Licensing Inspector reviewed the following at the time of inspection: fire drills, dietician reports, activity calendars, menus, and healthcare oversight.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2023Inspection2 violations
Inspection dates
05/22/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 05/20/2023 regarding allegations in the area(s) of: Resident care related to medication administration. 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on communication received from the facility via email on 05/20/2023 and an interview on 06/05/2023, the facility failed to ensure medications are administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The “Facility Incident/Accident Report dated 05/19/2023 at 12:00pm indicates resident #1 received another resident’s Oxycodone 5/325 by staff #1.
  2. The rights of medication administration outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing on page 25 #6 are as follows: 1. Right Client; 2. Right Medication; 3. Right Dose; 4. Right Route; 5. Right Time; 6. Right Documentation.
  3. The LI interviewed staff #2 on 06/06/2023 who confirmed staff #1 administered Oxycodone 5/325 to resident #1.
Plan of correction
The medication aide was counselled, and the error was discussed in detail with her. The administrator reviewed the rights of medication management. RIGHT Client, medication, Dose, route, time, documentation. Employee studied the current medication administration plan with this writer. Discussion ensued regarding distractions and the importance of staying focused. In addition to counsel, the RMA will complete a medication refresher course by 06/15/2023. Any further medications errors within 3 months of this incident will result in a report directly to the Board of Nursing.
22VAC40-90-40-B
Based on review of staff records, the facility failed to ensure criminal history reports are obtained on all staff within 30 days of hire.
Evidence
  1. The criminal history report for staff #1, hired on 03/02/2023 is dated 05/19/2023.
Plan of correction
Criminal history report for staff #1 was re-submitted for completed on 06/30/2023. Administrator will call Virginia State Police to obtain criminal history report ASAP. Future criminal history reports for new employees will be sent in a timely manner as required by DSS regulations.
July 27, 2022Complaint survey1 violation
Inspection dates
07/27/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/27/2022 from 10:00am through 4:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit meeting will be conducted to review the inspection findings. A complaint was received by VDSS Division of Licensing on 06/23/2022 regarding allegations in the area of administrator provisions and responsibilities The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit meeting will be conducted to review the inspection findings. A complaint was received by VDSS Division of Licensing on 06/23/2022 regarding allegations in the area of administrator provisions and responsibilities The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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
22VAC40-73-150-A
Based on document review and an interview, the facility failed to have an administrator of record.
Evidence
  1. The submitted renewal application dated 0726/2022 documents staff 1 as the facility manager.
  2. On 07/27/2022 the LI interviewed staff 1 who stated “I am not the administrator, I am the director and nurse of the facility.”
  3. On 07/27/2022, the LI interviewed collateral 1 by phone who confirmed staff 1 functions in the role as facility manager and the facility currently does not have a licensed administrator of record.
Plan of correction
Not published by VDSS.
July 27, 2022Inspection1 violation
Inspection dates
07/27/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/27/2022 from 10:00am until 4:30pm Number of residents present at the facility at the beginning of the inspection: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection 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
22VAC40-73-220-A
Based on review of staff records, and an interview, the facility failed to provide orientation and training to private duty personnel regarding the facility's policies and procedures related to the duties of the private duty personnel.
Evidence
  1. Staff 5, (agency staff) who started at the facility on 07/16/2022 did not have documentation of required orientation on file.
  2. The LI interviewed staff 8 who confirmed documentation of orientation was not on file for staff 5.
Plan of correction
Facility shall provide orientation and training to (Private Duty) or Agency personnel, regarding the Facility's policy and procedures related to their duties. 1. Agency staff signed facility orientation paperwork on 07/27/2022, after verifying that orientation was given on 07/16/2022. 2. All staff will orient Agency staff beginning their shift, and then sign the record of initial ALF staff training form. Agency staff will read and sign the Sworn Statement of Affirmation and the SP Direct Care Staff Guidelines and Expectations form. All signed forms will be placed in the back portion of the Resident Identification Binder.
March 21, 2022Inspection2 violations
Inspection dates
03/21/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
A renewal inspection was conducted by two LIs on 03/21/2022. The census was reported as 16. The facility was clean and free from any foul odors. Seven resident and two staff records were reviewed in addition to the activities calendar, menu, fire drills and staff schedules. There were two violations during this renewal inspection and information can be viewed on the violation notice of this report. If you have any questions, please contact the licensing inspector at (540) 292-5932 or email rhonda.whitmer@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on documentation, the facility failed to implement procedures for maintenance of scheduled II-V medications outlined in the facility's medication management plan.
Evidence
  1. The facility medication management plan revised 09/07/2021 #10 Maintenance of Schedule II-V Medications within Shenandoah Place indicates "medications will be counted by an RMA/LPN from the off going shift and one from the oncoming shift. The procedure will occur at the beginning and end of all three shifts in the facility. Both staff's signatures and the count obtained will be documented on either the Schedule II Count Sheet provided by the facility pharmacy or the facility's Controlled Medication Inventory sheet.
  2. The Controlled Drug Administration Record for resident 1's Lorazepam does not contain initials for the off going 11-7 to 7-3 shift on 03/03/2022, 03/11/2022 and 03/12/2022.
  3. The Controlled Drug Administration Record for resident 1's Lorazepam does not contain initials for the oncoming 7-3 to 3-11 shift on 02/28/2022, 03/01/2022, 03/02/2022, 03/05/2022, 03/06/2022, 03/19/2022 and 03/20/2022.
  4. The Controlled Drug Administration Record for resident 1's Lorazepam does not contain initials for the off going 3-11 to 11-7 shift on 02/28/2022, 03/01/2022, and 03/02/2022.
  5. The Controlled Drug Administration Record for resident 1's Lorazepam does not contain initials for the oncoming 3-11 to 11-7 shift on 03/02/2022, 03/10/2022, 03/11/2022, 03/17/2022 and 03/18/2022.
  6. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the off going 11-7 to 7-3 shift on 03/03/2022, 03/10/2022, 03/11/2022 and 03/12/2022, 03/18/2022, 03/19/2022 and 03/20/2022.
  7. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the off going 7-3 to 3-11 shift on 03/01/2022, 03/11/2022, 03/14/2022.
  8. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the oncoming 7-3 to 3-11 shift on 02/28/2022, 03/01/2022, 03/02/2022 and 03/05/2022, 03/06/2022, 03/10/2022, 03/19/2022 and 03/20/2022.
  9. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the off going 3-11 to 11-7 shift on 02/28/2022, 03/02/2022, 03/10/2022, 03/17/2022 and 03/20/2022.
  10. The Controlled Drug Administration Record for resident 2's Tramadol does not contain initials for the oncoming 3-11 to 11-7 shift on 03/02/2022, 03/10/2022, 03/11/2022 and 03/17/2022, 03/18/2022 and 03/20/2022.
  11. The Controlled Drug Administration Record for resident 3's Oxycodone does not contain initials for the off going 11-7 to 7-3 shift on 03/03/2022, 03/11/2022, 03/12/2022, 03/18/2022, and 03/19/2022.
  12. The Controlled Drug Administration Record for resident 3's Oxycodone does not contain initials for the oncoming 7-3 to 3-11 shift on 03/02/2022, 03/05/2022, 03/06/2022, 03/10/2022, 03/18/2022, 03/19/2022 and 03/20/2022.
  13. The Controlled Drug Administration Record for resident 3's Oxycodone does not contain initials for the off going 3-11 to 11-7 shift on 03/02/2022, 03/10/2022 and 03/18/2022.
  14. The Controlled Drug Administration Record for resident 3's Oxycodone does not contain initials for the oncoming 3-11 to 11-7 shift on 03/02/2022, 03/10/2022, 03/11/2022, 03/17/2022, and 03/18/2022
Plan of correction
Laura Fasching, LPNM, Facility Manager, will conduct a weekly review, on Wednesdays, of the controlled substance count sheets and the shift change record to assure that all medication personnel are identified for each shift by initials placed in the appropriate location. Review of the count sheets will verify both correct completion and count of medication on the record. Each review will be identified by the placement of initials and date in the margin beside each Wednesday entry on the form. All medication staff will receive follow up training on the Shenandoah Place Medication Administration Plan as well as review of proper procedures for the storage, counting and documentation of controlled medications.
22VAC40-73-860-I
Based upon direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are stored in a locked area.
Evidence
  1. During a walk through of the facility, the LI observed the housekeeping cart in the hallway unlocked and unattended that contained multiple bottles of cleaning supplies.
  2. During a walk through of the facility, the LI observed the door to the beauty shop open and unattended. The counter contained a dispenser of disinfectant solution.
Plan of correction
Ongoing training and monitoring will occur at Shenandoah Place for proper storage of the housekeeping cart. The cart will be in direct sight and control of the person using at all times. While not in use, the cart will be maintained behind a locked door. Doors to rooms in which potentially hazardous chemicals are stored shall remain locked and inaccessible to persons other than SP staff.
November 3, 2021Inspection2 violations
Inspection dates
11/03/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS
Comments
An unannounced monitoring inspection was conducted. The focus of the inspection was to determine whether the provider had corrected or is in the process o correcting previously cited violations within the area of the standards referenced above. Any non-compliant elements of law or regulations are documented in the Violation Notice of this inspection.
Violations
22VAC40-73-680-K
Based on review of residents' records, the facility failed to ensure PRN medication orders contain all required conditions when medication aides administer the PRN medication.
Evidence
  1. The Medication Administration Record (MAR) for resident 1 shows medication aides administered PRN medication for the month of October.
  2. Resident 1 has the following order: Buspirone 5mg tablet-Take one tablet by mouth two times daily as needed for anxiety disorder.
  3. The physician's order does not include symptoms that indicate the use of the medication and the exact time frames the medication is to be given in a 24 hour period.
Plan of correction
In process of obtaining written order from resident's physician. The order shall include symptoms that indicate the use of the medication, the exact dosage, the exact time frames the medication is to be given in a 24 hour period, and directions as to what to do if symptoms persist. The nurse manager will oversee all future PRN orders to evaluate whether they follow stated regulation.
22VAC40-73-680-D
Based on a review of residents' records, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber'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. Page 181 of the current registered medication aide curriculum approved by the Virginia Board of Nursing indicates "medication aides may not assess for medical need nor the assessment of the medical need be delegated to an unlicensed person by a registered nurse of a physician."
  2. Resident 1 has the following order: Buspirone 5mg tablet-Take one tablet by mouth two times daily as needed for anxiety disorder.
  3. The October Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/18/2021 at 5:22am "given to patient for agitation before Activities Daily Living (ADLs) are performed"
  4. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/19/2021 at 5:25am "for staff to be able to give ADLs safely"
  5. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/19/2021 at 5:32pm "resident seems agitated and anxious"
  6. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/20/2021 at 2:33pm "agitation"
  7. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/23/2021 at 5:19am "to help with aggressive behavior during ADLs"
  8. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/26/2021 at 6:08am "to control violent outbursts during ADLs"
  9. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/27/2021 at 5:41am "to control violent outbursts towards staff during ADLs"
  10. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/27/2021 at 3:54pm "Resident seems very anxious trying to get out of chair"
  11. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/29/2021 at 2:33pm "to control violent outbursts during ADLs"
  12. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/29/2021 at 6:25pm "resident is combative"
  13. Documentation on Medication Administration Record (MAR) for resident 1 indicates medication was administered on 10/31/2021 at 5:46am "to control violent outbursts during ADLs"
  14. Documentation on Medication Administration Record (MAR) for resident 1 indicates staff 1, 2 3 and 4 who administered the medication, are registered medication aides.
Plan of correction
All Registered Medication Aides (RMAs) are in the process of re-training specifically regarding documentation in PRN administration circumstances and recertification of medication aide training (yearly). Ongoing training occurs with RMA staff related to resident redirection, de-escalation technique to utilize if resident appears combative or displays hitting actions to ensure that resident care is managed in a safe and appropriate manner.
October 25, 2021Inspection0 violations
Inspection dates
10/25/2021
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS
Technical assistance
As a result of preliminary findings of the investigation of a self-reported incident on 10/17/2021,the following technical assistance was discussed by telephone with the acting administrator on 10/27/2021: Reassess the appropriateness of continued placement based on a 10/21/2021 document titled "Safety Agreement", submitted by the facility on 10/26/2021. The facility is recommended to reassess the resident's current needs, determine if continued placement is appropriate, and develop and implement a plan for the resident's supervision relating to cognitive functioning and impulse control in collaboration with the local CSB.
Comments
A non-mandated self-report inspection was initiated on 10/25/2021 and concluded on 10/27/2021. A (self-reported incident was received by the department regarding allegations in the areas of admission, retention and discharge of residents. The acting administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the (acting administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 16, 2021Inspection2 violations
Inspection dates
08/16/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 The Criminal History Record Report
Comments
A non-mandated focused monitoring inspection was initiated on 08/16/21 and concluded on 08/19/21 The acting administrator was contacted by telephone to conduct the investigation. The acting administrator reported the current census as 18.The licensing inspector emailed the acting administrator a list of items required to complete the investigation. The evidence gathered during the inspection determined non-compliance(s) with standards or law, and violations were issued. Upon the receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance; 2) measures to prevent re-occurrence; 3) person(s) responsible for implementing each step and monitoring preventative measures; 4) the date by which the non-compliance will be corrected.
Violations
22VAC40-73-450-C
Based on record review, the facility failed to ensure that Individual Service Plans (ISPs) included all required components.
Evidence
  1. The Uniform Assessment Instrument (UAI) for resident 1, dated 05/15/21 shows the resident is assessed as needing staff assistance with dressing. The ISP dated 05/12/21 indicates no assistance is needed. The Uniform Assessment Instrument (UAI) for resident 1, dated 05/15/21 shows the resident is assessed as needing medication administration by professional nursing staff. The ISP dated 05/12/21 indicates medication administration by a registered medication aide.
  2. The Uniform Assessment Instrument (UAI) for resident 2, dated 11/10/20 shows the resident is assessed as needing mechanical assistance with walking. This is not addressed on the ISP dated 11/10/20. The Uniform Assessment Instrument (UAI) for resident 2, dated 11/10/20 shows the resident is assessed as disoriented to some spheres some of the time. The ISP dated 11/10/20 indicates resident is oriented to all spheres. The Uniform Assessment Instrument (UAI) for resident 2, dated 11/10/20 shows the resident is assessed as needing medication administration by professional nursing staff. The ISP dated 11/10/20 indicates medication administration by a registered medication aide.
Plan of correction
As part of the change of administrators at SP, all UAIs and service plans were being re-written prior to this inspection. Resident 1, as identified in the violation, is not currently in the facility, but in a rehab unit, therefore his documents were not reviewed. The person reviewing documents did not know this individual and was unable to complete the documents without firs evaluating, which would be done upon return to the facility from the rehabilitation unit.
22VAC40-90-40-B
Based on record review, the facility failed to ensure a criminal history report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The criminal history report for staff 1 is dated 08/17/21. Staff 1 started employment on 07/13/21.
  2. The criminal history report for staff 2 is dated 08/17/21. Staff 2 started employment on 07/12/21.
  3. The criminal history report for staff 3 is dated 08/11/20. Staff 3 started employment on 06/14/21.
Plan of correction
All 3 staff mentioned in the violation were hired and began work under the previous administrator. Upon review of the staff charts by the acting administrator, it was noted that these charts lacked criminal history checks which were immediately obtained from the website.
August 6, 2021Inspection1 violation
Inspection dates
08/06/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 08/06/21 and concluded on 08/19/2021. A self-reported incident was received by the department relating to medication management. The acting administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the acting administration a list of documentation required to complete the investigation The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the/self-report but identified during the course of the investigation can be found on the violation notice. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance;2) measures to prevent re-occurrence; 3) person(s) responsible for implementing each step and monitoring preventative measures; 4) the date by which the non-compliance will be corrected
Violations
22VAC40-73-640-A
Based on document review and an interview, the facility failed to implement a written plan for medication management to ensure medications are refilled in a timely manner.
Evidence
  1. The acting administrator reported to the licensing office on 07/23/21 that resident 1 did not receive three doses of scheduled medication due to medication not being available for administration.
  2. The July 2021 Medication Administration Record (MAR) for resident 1 indicates Oxycodone was not available for administration on 07/18/21 at 6:00pm; 07/19/21 at 6:00am and 12:00pm.
  3. Interview with acting administrator on 08/06/21 at 4:56pm confirmed medication was not available for administration.
Plan of correction
RMA supervisor is assigned to re-order medications in a timely manner according to the medication administration plan and report any potential difficulty with the process. Administrator will review medication re-orders with RMA supervisor once weekly to ensure that physician's orders are up to date and medications are on hand.
June 22, 2021Inspection4 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Technical assistance
Recommend adding "call 911" to MAR for nitroglycerin orders as it pertains to residents D and F; add "take pulse" and hold per instructions obtained from resident's physician.
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 06/22/21 and concluded on 07/06/21. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 16. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed a selected portion of six resident records ,medication certification for one staff, and incident reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance; 2) measures to prevent reoccurrence; 3) person(s) responsible for implementing each step and monitoring preventative measures; 4) The date by which non-compliance will be corrected.
Violations
22VAC40-73-440-D
Based upon review of residents' records, the facility failed to ensure the Uniform Assessment Instrument (UAI) is included all required information. FINDINGS: 1) The UAIs for residents A and B do not include phone number and social security number. 2) The UAIs for residents D and F do not include a social security number. 3) The UAI for resident E does not include address, phone, date of birth, and section for ambulation assistance is not completed.
Plan of correction
Administrator to review and correct UAI.
22VAC40-73-450-C
Based upon review of residents' records, the facility failed to ensure the assessed needs of the resident are included on the Individualized Service Plan (ISP). FINDINGS: 1) The Uniform Assessment Instrument (UAI) for resident A indicates a wheelchair is needed for toileting and transferring. The ISP indicates mechanical assistance of walker a. The UAI indicates wheelchair is used for long distances. b. Physician's order dated 06/03/21 indicate resident has special diet of no added sugar; this is not indicated on the ISP. 2) The UAI for resident C indicates wandering less than weekly. This is not indicated on the ISP. 3) The UAI for resident D indicates a wheelchair is needed for toileting. The ISP indicates on the transferring section only use of walker in bathroom. a. The UAI for resident D indicates mechanical and human assistance is needed with stairclimbing. This is not indicated on the ISP. 4) The ISP for resident F indicates mechanical assistance of wheelchair walker and handrails for toileting. The ISP indicates on the transferring section use of walker and handrails in bathroom. a. The UAI indicate resident uses urinal at night. This is not indicated on the ISP. b. The UAI indicates no assistance is needed with wheeling. The ISP indicates staff will provide physical assistance with wheeling. c. The UAI indicates mechanical assistance is needed with stairclimbing. This is not indicated on the ISP. d. The physical exam dated 05/24/21 indicates special diet of no added salt regular texture. The ISP indicates regular diet.
Plan of correction
Administrator/LPN to review and correct care plans.
22VAC40-73-450-D
Based upon review of residents' records, the facility failed to ensure services provided by hospice are included on the Individualized Service Plan (ISP). FINDINGS: The hospice plan of care for resident C indicates resident receives skilled nursing services, aide services, chaplain and volunteer services. a. The ISP indicates nursing oversight for co-morbidities, care and support for resident and family.
Plan of correction
Administrator/LPN to review and correct care plans.
22VAC40-73-930-D
Based upon review of residents' records, the facility failed to indicate the inability to use the call bell system on resident B's Individualized Service Plan (ISP) FINDINGS: 1) The physical exam for resident B dated 04/03/21 indicates resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person. a. The physical exam also indicates resident B has a history of head trauma, pelvic fracture, arm and hip fracture. b. The Uniform Assessment Instrument (UAI) for resident B indicates resident is disoriented with short term memory loss. c. The ISP does not indicate the inability to use the signaling device and specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.
Plan of correction
Administrator/LPN to review and correct care plans.
April 26, 2021Complaint survey2 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 04/26/21 and concluded on 05/12/21. A complaint was received by the department regarding allegations in the area of medication administration. The administrator was contacted to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint, but identified during the course of the investigation can be found on the violation notice. Upon receipt of the violation notice, a plan of correction is requested for each violation. The plan of correction should include 1) Steps to correct noncompliance of the regulation; 2) Measure(s) to prevent re-occurrence of noncompliance; 3) Person(s) responsible for implementing each step and/or monitoring any preventative measure(s) and 4) The date by which the noncompliance will be corrected.
Violations
22VAC40-73-640-A
Based upon review of residents' Medication Administration Records (MARs), the facility failed to implement procedures in the medication management plan to ensure documentation of effectiveness of "as needed" PRN medications. FINDINGS: 1) The facility medication management plan indicates a daily review of the medication administration records by the director of nursing, administrator or the medication supervisor shall be performed to ensure accurate and complete documentation to include timely documentation of PRN medication. 2) Resident A has the following order: Acetaminophen 325mg-Take 2 tablets by mouth every 4 hours as needed for mild pain or fever greater than 99 degrees Fahrenheit. Do not exceed 3gm Acetaminophen in 24 hours from all sources. Notify MD if no relief in 24 hours. a. Documentation in the MAR indicates medication was administered on 04/06/21 at 11:39pm for left ankle pain. b. Results following the administration of medication were documented at 5:33am on 04/07/21 and indicate "resident said it helped." c. Documentation in the MAR indicates medication was administered on 04/10/21 at 2:39am for headache. d. Results following the administration of medication were documented at 6:12am and indicate "resting in bed with eyes closed." 3) Resident G has the following order: Ibuprofen 200mg-Take 2 tablets by mouth every 4 hours as needed for pain or fever. Call hospice if symptoms persist greater than 24 hours. a. Documentation in the MAR indicates medication was administered on 04/11/21 at 1:38am. b. Results following the administration of medication were documented at 4:00am and indicate "resident in bed with eyes closed."
Plan of correction
Medication management plan updated to define "timely" as it is open to interpretation; updated on 05/17/21. In-service scheduled to review updated plan with staff for 05/26/21.
22VAC40-73-670-1
Based upon review of staff records and resident records, the facility failed to ensure staff administering medications are licensed by the Commonwealth of Virginia or is registered with the Virginia Board of Nursing as a medication aide. FINDINGS: Based upon review of the Medication Administration Records (MARs), documentation indicates staff A administered medications to residents A, B, C, D, E, F, G, H, I, J, and K on 04/09/21. a. Documentation submitted by the facility indicates staff A received an Associate of Applied Science Degree in Nursing on 05/08/2017. b. Staff A has not successfully taken the National Council Licensure Examination to obtain licensure as a registered nurse. c. Communication received from the administrator via email on 02/22/21 included a copy of an application for staff A to take the registered medication aide competency exam dated 02/22/21. The administrator indicated in the email received on 02/22/21 that staff A had been pulled from the medication cart. d. An email was received from the administrator on 04/14/21 containing a letter from the Commonwealth of Virginia dated 04/13/21 indicating staff A is authorized to practice as a provisional medication aide effective 04/13/21. e. Documentation in the Medication Administration Records (MARs), indicates staff A administered medications to residents A, B, C, D, E, F, G, H, I, J, and K on 04/09/21, which was prior to the authorization letter of 04/13/21.
Plan of correction
All staff scheduled to pass medications will have an approval letter to do so.
February 16, 2021Inspection11 violations
Inspection dates
Feb. 16, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 02/16/2021 and concluded on 03/15/2021. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 11. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed a selected portion of nine resident records ,licenses and certifications for five staff, staff schedule and incident reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return to the inspector within 10 days. The plan of correction is to include the following: 1) steps to correct the non-compliance with the standards, 2) measures to prevent the non-compliance from occurring again, and 3) person(s) responsible for implementing each step and or monitoring any preventative measure(s).
Violations
22VAC40-73-70-A
Based upon review of residents' records, the facility failed to report within 24 hours, a major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident. FINDINGS: 1) A review of requested incident reports submitted for this focused inspection indicate resident A had a falls on 01/24/21 at 12:15am and on 01/30/21 at 10:22pm. a. Neither of the above listed incidents were reported to the regional licensing office within 24 hours. 2) Nurses notes for resident E dated 02/02/21 indicate ?Skilled nursing evaluation completed for buttock wounds. Stage II pressure ulcers were found to left and right buttocks due to shears friction.“ Notes dated 02/25/21 indicate ”Skilled nursing visit for wound care. New openings to left and right buttocks were noted, old areas are healed.? a. This was not reported to the regional licensing office within 24 hours. b. Communication received from the administrator on 03/02/21 "there are wounds, but there are no pressure areas." 3) A review of requested incident reports submitted for this focused inspection indicate resident E had falls on 12/14/20 at 3:32pm; 01/18/21 at 9:30pm ; date unknown on another report at 5:00pm; and 02/07/21 at 6:05am. a. These incidents were not reported to the regional licensing office within 24 hours. 4) A review of requested incident reports submitted for this focused inspection indicate resident F had falls on 01/21/21 at 6:30pm; 01/23/21 at 6:02pm; 01/27/21 at 6:42pm; 01/27/21 at 11:15am and 02/10/21 at 3:15pm. a. These incidents were not reported to the regional licensing office within 24 hours. 5) A review of requested incident reports indicate resident H had a fall on 02/07/21 at 6:40am and another incident report indicates a fall but does not include date or time. a. This was not reported to the regional licensing office within 24 hours. 6) A review of requested incident report indicate resident I had a fall on 02/04/21 at 7:32pm. a. This was not reported to the regional licensing office within 24 hours.
Plan of correction
Not published by VDSS.
22VAC40-73-70-B
Based upon review of incident reports, the facility failed to ensure the reports contained all required information. FINDINGS: 1)There are two submitted reports requested for this focused inspection for resident C that do not include date of incident and actions taken in response to the incident. Both incident reports indicate time of incident as 5:00pm. 3) There are two submitted reports ( 01/23/21 at 6:02pm and 01/27/21 at 11:15am) requested for this focused inspection for resident F that do not include actions taken in response to the incident. 4) The submitted incident report requested for this focused inspection for resident H does not include a date or time and actions taken in response to the incident. 5) The submitted incident report requested for this focused inspection for resident I, (02/04/21 at 7:32pm) does not include actions taken in response to the incident.
Plan of correction
Not published by VDSS.
22VAC40-73-70-C
Based upon review of residents' records and communication with the administrator, the facility failed to submit a written report within seven days from the date of the incident. FINDINGS: 1) A review of requested incident reports submitted for this focused inspection indicate resident A had a fall on 01/24/21 at 12:15am and on 01/30/21 at 10:22pm. a. Written reports for the above listed incidents were not submitted to the regional licensing office within seven days of the incident. 2) Nurses notes requested for this focused inspection for resident E dated 02/02/21, indicate ?Skilled nursing evaluation completed for buttock wounds. Stage II pressure ulcers were found to left and right buttocks due to shears friction.? Notes dated 02/25/21 indicate ?Skilled nursing visit for wound care. New openings to left and right buttocks were noted, old areas are healed.? a. A written report was not submitted to the regional licensing office within seven days of the incident. b. Communication received from the administrator on 03/02/21 "there are wounds, but there are no pressure areas." 3) A review of requested incident reports submitted for this focused inspection indicate resident E had a fall on 12/14/20 at 3:32pm; 01/18/21 at 9:30pm ; date unknown on another report at 5:00pm; and 02/07/21 at 6:05am. a. Written reports for the above listed incidents were not submitted to the regional licensing office within seven days. 4) A review of requested incident reports submitted for this focused inspection. indicate resident F had falls on 01/21/21 at 6:30pm; 01/23/21 at 6:02pm; 01/27/21 at 6:42pm; 01/27/21 at 11:15am and 02/10/21 at 3:15pm. a. Written reports of the above listed incidents were not reported to the regional licensing office within seven days. b. Three of the five reports reviewed did not contain the signature of the administrator. 5) A review of requested incident reports submitted for this focused inspection indicate resident H had a fall on 02/07/21 at 6:40am and another incident report indicates a fall but does not include date , time and administrator signature. 6) A review of requested incident report submitted for this focused inspection indicates resident I had a fall on 02/04/21 at 7:32pm.
Plan of correction
Not published by VDSS.
22VAC40-73-325-C
Based upon review of submitted documentation, the facility failed to ensure documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls was completed as required. 1) The incident report for resident C dated 01/20/21 indicates "resident rang call bell and was on floor." a. There is no documentation of analysis of the circumstances of the fall. Intervention initiated is documented as "remind resident to call for help." 2) The incident report for resident F dated 02/10/21 indicates "resident was observed on floor, we got him up and put resident in wheelchair and brought resident out for coffee." a. As completed, the post fall form does not document the circumstances of the fall or interventions initiated to prevent or reduce the risk of subsequent falls. The post fall form indicates the analysis of the circumstances of the fall as resident is "actively dying." Intervention initiated is documented as “checks.”
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based upon review of residents' records. the facility failed to ensure the assessed needs of the resident are included on the Individualized Service Plan (ISP). FINDINGS: 1) The Uniform Assessment Instrument (UAI) dated 02/23/21 for resident A indicates the assistance of two staff is needed for dressing. This is not reflected on the ISP (dated 02/23/21) a. The ISP does not include a description of identified needs sufficient to explain the inconsistencies between reports. The for resident A indicates “wandering/passive, weekly or more.” The ISP and hospice plan of care indicate resident A is bedbound. b. The hospice plan of care indicates resident has an indwelling foley catheter. The UAI indicates the resident wears briefs. The ISP indicates ?Client does not currently use the restroom; is incontinent of both bowel and bladder and will be provided incontinent care while in bed.? c. The UAI indicates the assistance of two staff is needed for bathing. The ISP indicates one or two staff is needed. 2) The UAI for resident C (dated 02/23/21) indicates wandering passive weekly or more and disorientation to some spheres some of the time. This is not reflected on the ISP dated 02/23/2021. 3) Nurses notes dated 02/02/21 indicate resident E has a stage II pressure ulcer This identified need is not indicated on 3) Nurses notes dated 02/02/21 indicate resident E has a stage II pressure ulcer. This identified need is not indicated on the ISP review dated 02/09/21. The ISP indicates resident is as risk for alteration in skin integrity and has a history of wounds. 4) Post fall assessment tool dated 01/23/2021 indicates resident F has a fall mat and requires frequent checks due to falls. This need for frequent checks is not reflected on the ISP.
Plan of correction
Not published by VDSS.
22VAC40-73-450-D
Based upon review of residents' records, the facility failed to ensure services provided by hospice is included on the Individualized Service Plan (ISP). FINDINGS: 1) The hospice plan of care for resident A indicates resident receives skilled nursing services, volunteer services and social worker services. a. The ISP indicates comfort medications, care/oversight services.
Plan of correction
Not published by VDSS.
22VAC40-73-470-F
Based upon review of documentation, the facility failed to ensure medical attention was received immediately from a licensed health care professional when a resident suffers a serious accident, injury, illness, medical condition or there is reason to suspect that such has occurred. 1) Incident reports that were requested for this focused inspection and submitted by the administrator show that resident F had falls on 01/23/21 at 6:02pm; 01/27/21 at 6:42pm; 01/27/21 at 11:15am and 02/10/21 at 3:15pm. a. There is no documentation indicating the resident was seen by a licensed health care professional for the falls that occurred on 01/23/21 at 6:02pm; 01/27/21 at 6:42pm; 01/27/21 at 11:15am and 02/10/21 at 3:15pm. b. There is no documentation the resident's physician was notified within 24 hours of the falls that occurred on 01/23/21 at 6:02pm; 01/27/21 at 6:42pm; 01/27/21 at 11:15am and 02/10/21 at 3:15pm as required by 22 VAC 40-73-470-F.1. 2) Incident reports that were requested for this focused inspection and submitted by the administrator show that resident E had falls on 12/14/20 at 3:32pm; 01/18/21 at 9:30pm ; date unknown on another report at 5:00pm; and 02/07/21 at 6:05am. a. Documentation indicates resident hit head on night stand and rescue squad was called on 02/07/21 but resident refused to go to the hospital. b. There is no documentation of resident being seen by a licensed health care professional for the falls that occurred on 12/14/20 at 3:32pm; 01/18/21 at 9:30pm ; date unknown on another report at 5:00pm; and 02/07/21 at 6:05am.. c. There is no documentation the resident’s physician’s was notified within 24 hours of the falls that occurred on 12/14/20 at 3:32pm; 01/18/21 at 9:30pm ; date unknown on another report at 5:00pm; and 02/07/21 at 6:05am as required by 22 VAC 40-73-470-F.1.
Plan of correction
Not published by VDSS.
22VAC40-73-670-1
Based upon review of staff records and resident records, the facility failed to ensure staff administering medications are licensed by the Commonwealth of Virginia or is registered with the Virginia Board of Nursing as a medication aide. FINDINGS: Documentation submitted by the facility indicates staff A received an Associate of Applied Science Degree in Nursing on 05/08/2017. a. Staff A has not successfully taken the National Council Licensure Examination to obtain licensure as a registered nurse. b. Communication received from the administrator via email on 02/24/21 indicates that staff A is able to test for the National Council Licensure Examination from 02/24/21 through 08/23/21. c. Staff A has not taken the Virginia Board of Nursing competency exam for registered medication aides. d. Communication received from the administrator via email on 02/22/21 included a copy of an application to take the registered medication aide competency exam for staff A dated 02/22/21. Administrator indicated that staff A had been pulled from the medication cart. e. The file for staff A contains a Registered Medication Aide job description signed by staff A dated 02/01/2021. The job description indicates a requirement is having a current registration in Virginia as a registered medication aide. f. Communication received from the administrator on 03/01/21 states staff A passed medications on 02/06/21 from 11p- 11a, 02/07/21 11p-7a, 02/11/21 3p-11p, 02/12/21 7p-7a, 2/18/21 3p-11p and 2/20/21 3p-7a. g. Based upon review of the Medication Administration Records (MARs) documentation indicates staff A administered medications to residents A, B, C, D, E, and F on 02/01/21; 02/02/21; 02/04/21; 02/06/21; 02/07/21; 02/08/21; 02/11/21; 02/12/21; 02/13/21 and 02/14/21. h. Based upon review of the MARS for resident F, documentation indicates staff A administered medication to resident F on 03/08/21 and 03/09/21.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based upon review of resident records, the facility failed to ensure medications are administered in accordance with the 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. FINDINGS: 1)Resident F has the following two orders: Ondansetron 8mg tablet-Take one tablet by mouth 30 minutes before getting out of bed for nausea. Ondansetron 8mg tablet-Take one tablet by mouth every four hours as needed for nausea. O da set o 8 g tab ausea. a. Documentation in the Medication Administration Record (MAR) indicates medication was administered by staff A on 02/08/21 at 4:44am and at 6:00am. Resident F received two doses of medication in less than four hours apart. 2) Resident G has the following order: Novolog Insulin 100U/ML Pen-Inject 6 units into the skin three times daily before meals . Hold if blood sugar is less than 90. a. Documentation in the MAR indicates resident's blood glucose was 90 on 01/25/21 at 7:30am and insulin was not administered. b. Documentation in the MAR indicates resident's blood glucose was 90 on 02/12/21 at 7:30am and insulin was not administered.
Plan of correction
Not published by VDSS.
22VAC40-73-680-E
Based upon review of medication administration records, the facility failed to ensure medical procedures are provided according to the physician's instructions. FINDINGS: 1) Resident A has the following order: Check blood pressure daily. Notify MD if Systolic (top) is greater than 160 and/or diastolic (bottom) is greater than 90. a. Documentation in the Medication Administration Record (MAR) indicates resident's blood pressure was 167/53 on 01/15/21; 166/86 on 01/16/21; 176/63 on 01/17/21; 181/67 on 01/18/21; 175/64 on 01/21/21; 176/62 on 01/22/21; 166/53 on 01/23/21; 165/57 on 01/25/21; 171/51 on 01/27/21; 187/60 on 01/29/21; 175/56 on 01/30/21; 170/55 on 01/31/21; 177/59 on 02/03/21. b. There is no documentation of physician notification for systolic blood pressure over 160 on the days indicated above.
Plan of correction
Not published by VDSS.
22VAC40-73-680-K
Based upon review of resident's records, the facility failed to ensure physician's orders include all required information. FINDINGS: 1) Resident G has the following order: Glucose 4 GM tablet-Chew 4 tablets by mouth as needed for low blood sugar. Notify MD if no relief. a. The order on the MAR and the physician’s order sheet does not specify time frame to notify physician if no relief. . 2) Resident G has the following order: Nitroglycerin SL 0.4mg tablet-Place one tablet (0.4 mg total) under the tongue every 5 minutes as needed for chest pain. a. The order on the MAR and the physician’s order sheet do not indicate specific indications such as maximum dose to be given within a specified time frame and actions to take if symptoms persist.
Plan of correction
Not published by VDSS.