Inspection Reports for
Shenandoah Place, Inc.
50 Burkholder Lane, NEW MARKET, VA, 22844
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
15 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Renewal
Census: 15
Deficiencies: 5
Date: Aug 4, 2025
Visit Reason
The inspection was a renewal type conducted to assess compliance with applicable standards and laws for the facility license renewal.
Findings
The inspection found non-compliance with several standards related to resident admission documentation, emergency preparedness plan reviews, and practice exercises for resident emergencies. Violations were documented and a plan of correction was requested.
Deficiencies (5)
Facility failed to ensure the administrator provided written assurance to the resident that the facility had the appropriate license at admission.
Facility failed to document acknowledgement of orientation for new residents including emergency response procedures, mealtimes, and use of the call system.
Facility failed to implement a semi-annual review of the emergency preparedness plan with all staff and residents.
Facility failed to ensure an annual review of the emergency preparedness plan.
Facility failed to ensure practice exercises on procedures for resident emergencies were practiced every six months by all staff on each shift.
Report Facts
Number of residents present: 15
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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill James | Licensing Inspector | Conducted the inspection and is mentioned in relation to findings and contact information |
| Staff 1 | Acknowledged missing documentation and interview evidence related to deficiencies |
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 4
Date: Aug 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2025-03-13 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint was received on 2025-03-13 regarding allegations in resident care and related services. The evidence gathered did not support the allegation of non-compliance with standards or law.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified during the inspection. These violations involved failures to complete annual assessments and reviews, including tuberculosis risk assessment, Uniform Assessment Instrument, individualized service plan, and resident rights review.
Deficiencies (4)
Facility failed to ensure a risk assessment for tuberculosis (TB) was completed on an annual basis.
Facility failed to ensure that a Uniform Assessment Instrument (UAI) was completed on an annual basis.
Facility failed to ensure that the individualized service plan (ISP) was updated every 12 months.
Facility failed to ensure a review of resident rights was completed annually.
Report Facts
Residents present: 15
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill James | Licensing Inspector | Inspector conducting the complaint investigation and inspection |
| Staff 1 | Acknowledged failures related to TB screening, UAI reassessment, ISP updates, and resident rights review |
Inspection Report
Monitoring
Census: 16
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
The inspection was a monitoring visit to review resident care and related services at the facility.
Findings
The inspection found a self-reported medication administration error where medications prescribed to one resident were administered to another. Violations were issued based on this non-compliance with medication administration standards.
Deficiencies (1)
Facility failed to administer medications in accordance with physician's or prescriber's instructions and standards of practice, resulting in a medication error where Resident 1 was given medications prescribed to another resident.
Report Facts
Number of residents present: 16
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 16
Deficiencies: 7
Date: Oct 2, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found multiple violations including failure to properly train staff designated as Person-in-Charge, failure to post the current Person-in-Charge's name conspicuously, incomplete resident needs documentation on Individualized Service Plans, lack of oversight of special diets by a dietician or nutritionist, failure to conduct emergency preparedness orientation and semi-annual reviews, failure to review resident emergency procedures every six months, and failure to obtain timely criminal background checks for employees.
Deficiencies (7)
Facility failed to train staff member designated as Person-in-Charge on duties and responsibilities prior to placement.
Facility failed to post the name of the current on-site Person-in-Charge in a conspicuous place.
Facility failed to describe identified resident needs and dates on Individualized Service Plans as assessed by various instruments.
Facility failed to have oversight at least every six months of special diets by a dietician or nutritionist.
Facility failed to develop and implement orientation and semi-annual review on emergency preparedness and response plan for all staff, residents, and volunteers.
Facility failed to review procedures regarding resident emergencies at least every six months with all staff.
Facility failed to obtain criminal record reports on or prior to the 30th day of employment for multiple employees.
Report Facts
Number of residents present: 16
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
Fall Risk Assessment score: 20
Number of employees with late criminal background checks: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill James | Current Inspector | Named as the licensing inspector conducting the inspection |
| Sarah Pearson | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
Inspection Report
Renewal
Census: 19
Deficiencies: 0
Date: Aug 30, 2023
Visit Reason
The inspection was a renewal inspection conducted to review the facility's compliance with regulatory standards.
Findings
The Licensing Inspector reviewed multiple areas including administration, personnel, resident care, and emergency preparedness. Observations included resident activities and meals, review of records, fire drills, dietician reports, and healthcare oversight.
Report Facts
Records reviewed: 6
Interviews conducted: 8
Inspection Report
Monitoring
Deficiencies: 2
Date: May 22, 2023
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident regarding allegations related to medication administration.
Findings
The investigation confirmed non-compliance with medication administration standards and failure to obtain timely criminal history reports for staff. Violations were issued related to medication errors and staff background checks.
Deficiencies (2)
Facility failed to ensure medications are administered in accordance with physician's instructions and medication aide curriculum standards.
Facility failed to ensure criminal history reports are obtained on all staff within 30 days of hire.
Report Facts
Date of incident report: May 19, 2023
Date of staff hire: Mar 2, 2023
Date of criminal history report: May 19, 2023
Medication refresher course completion deadline: Jun 15, 2023
Criminal history report re-submission completion date: Jun 30, 2023
Inspection Report
Renewal
Census: 14
Deficiencies: 1
Date: Jul 27, 2022
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws related to orientation and training of private duty personnel, resulting in documented violations and a violation notice issued to the facility.
Deficiencies (1)
Facility failed to provide orientation and training to private duty personnel regarding the facility's policies and procedures related to their duties.
Report Facts
Number of residents present: 14
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
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 27, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-06-23 regarding allegations related to administrator provisions and responsibilities at the facility.
Complaint Details
The complaint was substantiated as evidence supported the allegation of non-compliance with standards regarding administrator provisions and responsibilities.
Findings
The investigation found non-compliance with regulations due to the facility failing to have a licensed administrator of record. Violations were issued based on document review and interviews confirming the absence of an administrator.
Deficiencies (1)
Facility failed to have an administrator of record.
Inspection Report
Renewal
Census: 16
Deficiencies: 2
Date: Mar 21, 2022
Visit Reason
A renewal inspection was conducted to evaluate compliance with regulatory standards and licensing requirements for the assisted living facility.
Findings
Two violations were identified during the renewal inspection: failure to properly implement procedures for maintenance of scheduled II-V medications, and failure to ensure cleaning supplies and hazardous materials were stored in a locked area.
Deficiencies (2)
Facility failed to implement procedures for maintenance of scheduled II-V medications as outlined in the medication management plan, with multiple instances of missing staff initials on controlled drug administration records.
Facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area, with housekeeping cart left unlocked and unattended and an open door to the beauty shop containing disinfectant solution.
Report Facts
Number of violations: 2
Number of resident records reviewed: 7
Number of staff records reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Fasching | LPNM, Facility Manager | Named in plan of correction for medication management deficiencies |
Inspection Report
Monitoring
Deficiencies: 2
Date: Nov 3, 2021
Visit Reason
An unannounced monitoring inspection was conducted to determine whether the provider had corrected or was in the process of correcting previously cited violations within the areas of administration, personnel, staffing, resident care, and emergency preparedness.
Findings
The facility was found to have deficiencies related to medication administration practices, specifically failing to ensure medications were administered according to physician orders and standards, and PRN medication orders lacking required conditions such as symptoms and exact time frames. Registered Medication Aides were retraining to address documentation and administration issues.
Deficiencies (2)
Facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions and consistent with approved medication aide standards.
Facility failed to ensure PRN medication orders contain all required conditions when medication aides administer the PRN medication.
Report Facts
Medication administration dates: 12
Inspection Report
Deficiencies: 0
Date: Oct 25, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident on 10/17/2021 regarding allegations in the areas of admission, retention, and discharge of residents.
Findings
The investigation did not find evidence to support the self-report of non-compliance with standards or law. Technical assistance was provided to reassess the resident's placement and supervision plan.
Inspection Report
Monitoring
Census: 18
Deficiencies: 2
Date: Aug 16, 2021
Visit Reason
A non-mandated focused monitoring inspection was initiated to investigate compliance with resident care and criminal history record report standards.
Findings
The inspection found non-compliance with standards related to Individual Service Plans not including all required components and failure to obtain criminal history reports on or prior to the 30th day of employment for staff.
Deficiencies (2)
Facility failed to ensure that Individual Service Plans (ISPs) included all required components, such as accurate assessment of resident needs.
Facility failed to ensure a criminal history report was obtained on or prior to the 30th day of employment for each employee.
Report Facts
Current census: 18
Staff with late criminal history reports: 3
Inspection Report
Deficiencies: 1
Date: Aug 6, 2021
Visit Reason
A non-mandated self-report inspection was initiated following a self-reported incident related to medication management to investigate compliance with medication administration standards.
Findings
The investigation confirmed non-compliance with medication management standards due to failure to implement a written plan ensuring timely medication refills, resulting in missed doses for a resident.
Deficiencies (1)
Facility failed to implement a written plan for medication management to ensure medications are refilled in a timely manner.
Report Facts
Missed medication doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill James | Inspector | Named as current inspector conducting the investigation. |
| RMA supervisor | Assigned to re-order medications and report difficulties as part of plan of correction. | |
| acting administrator | Interviewed and reported medication availability issues; involved in plan of correction. |
Inspection Report
Monitoring
Census: 16
Deficiencies: 4
Date: Jun 22, 2021
Visit Reason
A focused monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to review compliance with resident care and building standards.
Findings
The inspection found multiple non-compliances related to incomplete Uniform Assessment Instruments (UAI) and Individualized Service Plans (ISP), including missing resident information and discrepancies between assessments and care plans. Violations were documented and a plan of correction was requested.
Deficiencies (4)
Facility failed to ensure the Uniform Assessment Instrument (UAI) included all required information such as phone numbers, social security numbers, addresses, dates of birth, and ambulation assistance sections.
Facility failed to ensure the assessed needs of residents were accurately included on the Individualized Service Plan (ISP), with discrepancies noted between UAI and ISP regarding mobility, diet, and assistance needs.
Facility failed to ensure services provided by hospice were included on the Individualized Service Plan (ISP).
Facility failed to indicate the inability to use the call bell system on resident B's Individualized Service Plan (ISP).
Report Facts
Census: 16
Number of resident records reviewed: 6
Staff medication certification reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill James | Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 26, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding medication administration at the facility. The investigation was conducted remotely due to a state of emergency health pandemic.
Complaint Details
The complaint was related to medication administration. The evidence supported the allegation of non-compliance, including medication administration documentation issues and unlicensed staff administering medications.
Findings
The investigation found non-compliance with medication management procedures, specifically failure to document effectiveness of PRN medications and staff administering medications without proper licensure or registration. Violations were issued and plans of correction requested.
Deficiencies (2)
Failure to implement procedures in the medication management plan to ensure documentation of effectiveness of 'as needed' PRN medications.
Failure to ensure staff administering medications are licensed by the Commonwealth of Virginia or registered with the Virginia Board of Nursing as a medication aide.
Report Facts
Medication administration date: Apr 6, 2021
Medication administration date: Apr 10, 2021
Medication administration date: Apr 11, 2021
Medication administration date: Apr 9, 2021
Date of staff degree: May 8, 2017
Date of provisional medication aide authorization: Apr 13, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings for administering medications without proper licensure prior to authorization | |
| Jill James | Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Monitoring
Census: 11
Deficiencies: 9
Date: Feb 16, 2021
Visit Reason
A focused monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to review compliance with administrative, staffing, admission, retention, discharge, and resident care standards.
Findings
The inspection found multiple violations including failure to report major incidents within 24 hours, incomplete incident reports, failure to submit written reports within seven days, inadequate documentation and analysis of falls, incomplete individualized service plans, failure to ensure medical attention after serious incidents, unlicensed staff administering medications, and medication administration errors inconsistent with physician orders.
Deficiencies (9)
Facility failed to report within 24 hours major incidents affecting resident safety, including multiple falls.
Incident reports lacked required information such as date, time, and actions taken.
Facility failed to submit written reports within seven days from the date of incidents.
Failed to document analysis of falls and interventions to prevent subsequent falls.
Individualized Service Plans did not reflect assessed resident needs or hospice services.
Failed to ensure medical attention was received immediately after serious incidents and physician notification within 24 hours.
Staff administering medications were not licensed or registered as required.
Medications were not administered according to physician's instructions, including timing and notification requirements.
Physician's orders lacked required information such as specific indications and time frames for notification.
Report Facts
Number of incident reports missing required information: 7
Number of falls not reported within 24 hours: 17
Number of falls without physician notification within 24 hours: 9
Number of medication administration errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Unlicensed medication aide | Administered medications without proper licensure or registration; pulled from medication cart after administrator notification. |
| Jill James | Inspector | Conducted the focused monitoring inspection remotely. |
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