Shenandoah Center

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure resident's environment remained as free of accident hazards as is possible in regard to resident's rooms and vanity drawers, to be free of razors, scissors, and inedible care items in the 300 hall, mounted wall heater and broken inwall receded night light in resident bathroom, also resident's bedside table with a straw in her lotion bottle. This failed practice was a random opportunity for discovery. Resident identifier: #'s 3, 44, 50, 56 , and 88. Facility Census: 76. Findings Included: a) room [ROOM NUMBER] -During facility walk through and resident interviews on 03/05/26 at 10:56AM, 4 cans of shaving cream and 2 opened packages of razors, among other bathing products such as body lotions, shampoo, and mouthwash were found in the top 2 (two) drawers of the resident's shared sink/vanity area in room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. issues with food storage were found in the facility kitchen freezer This had the potential to affect all residents in the facility. Facility census: 76On 03/09/26 at 11:10 AM, during the 2nd kitchen visit, with the Corporate Dietary Manager (CDM) revealed the CDM acknowledged the following in the freezer : -1(one) opened box of frozen ground beef with inner plastic unsealed and left open to air -1(one) opened box of fish filet's with inner plastic unsealed and left open to air Interview with Kitchen Manager on 3/9/26 at 11:10 AM, He acknowledged the frozen ground beef and frozen fish filets were left open to air and stated the staff were supposed to tie the plastic to reseal once they have been opened. [...]

Inspectors wroteBased on observation, staff interview and resident interviews it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Several issues were identified related to staff response times to call lights. Facility census: 76. Findings Included:a) Resident #11On 03/05/26 at 2:50 PM after completing a representative Interview with Resident #11's family member outside his room, it was observed his call light was on. Upon walking into his room, he stated he was trying to call for staff. At 3:17PM two Nurse Aide (NA) #68 and #72 came in and asked if they could help him. Resident #11 asked for a glass of water and the bed pan. [...]

Inspectors wroteThe facility failed to ensure a dignified existence for residents. Resident #16 Based on observation and staff interviews the facility failed to ensure resident #16 had a right to a dignified existence Inside the facility. This failed practice was a random opportunity for discovery. Resident #16. Facility Census 76. Findings Included:On 03/04/2026 at 11:46 AM during a facility walk through on the 100 hall it was observed that Resident#16's private areas and brief was exposed with the room door wide open. Three staff members were observed present in the hall with visuals into the room and did not offer privacy for the resident prior to surveyor staff bringing it to Employee #36's attention. Employee #36 then stepped into the room and pulled the curtain for privacy. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed the resident at risk of not being informed of his rights prior to the end of Medicare Part A covered services. Resident identifier: #31. Facility census: 76.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a written Bed Hold Notice for one (1) of three residents. Resident #45 was discharged to an acute care setting. Resident Identifier: #45. Facility Census: 76.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure a resident received trauma-informed care which accounted for the resident's experiences and preferences in order to mitigate triggers that may cause re-traumatization. Resident identifier: #62. Facility census: 76.

Inspectors wroteBased on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . This failed practice was a random opportunity of discovery. Resident identifiers: #94, #9, #55, #12. Facility census: 76.- 03/04/26 at 12:04 PM: It was observed that Employee #7 handled Resident #94's hamburger buns without gloves.- 03/04/26 at 12:06 PM: During an interview, Employee #7 acknowledged the incident and stated she returned the plate to the kitchen for a replacement. - 03/04/26 at 9:55 AM: In room [ROOM NUMBER], the wheelchairs for Resident #9 and #55 had rips and tears on both armrests, exposing the inner padding.- 03/04/26 at 10:00 AM: [...]

Inspectors wroteTag F657 care plan timing and revision. Based upon record review and staff interview, the facility FAILED to ensure accurate and up to date information was reflected in the residents care plan for Resident #48. This was found to be true for one of three resident record reviewed. This has the ability to effect more then one resident.resident effected #48Residents reviewed #48, #72 and #60Census:

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure Resident #9 who requires dialysis received such services, in accordance with professional standards of practice. Resident #9 had an arteriovenous (AV) fistula in their left arm. The facility on multiple occurrences documented they were obtaining the residents blood pressure in their left arm. Obtaining blood pressure in the arm where the AV fistula is located may result in clots, clots that can dislodge, loss of use of the fistula and could cause a stroke. All of these things put the resident in an immediate risk of serious injury and/or death. The state agency (SA) determined this failure to be an immediate jeopardy (IJ) situation. The facility was notified of the IJ on 07/25/24 at 11:09 am. The SA accepted the facility's plan of correction (POC) on 07/25/24 at 1:15 PM. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an environment free from abuse and/or neglect from staff or other residents. Resident #123 was physically abused by Licensed Practical Nurse (LPN) #91. This created an immediate jeopardy situation. The LPN admitted to losing her temper and backhanding a combative resident. The facility took all appropriate steps after the situation including terminating the LPN. This issue is being cited as past noncompliance. Resident #23 was neglected by Nurse Aide (NA) #94. These were random opportunities for discovery. Resident identifiers: #123, and #23. Facility Census: 71.

Inspectors wroteBased on resident interview and record review the facility failed to ensure Resident #65 was free from significant medication errors. Resident #65 was administered an injection of 25 units of insulin on 04/19/24 when the resident was not ordered any insulin nor was he a diabetic. Giving a resident an insulin injection when they are not ordered the medication, nor a diabetic can cause serious consequences including serious harm and or death. The state agency (SA) determined this to be an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 07/22/24 at 6:49 PM. The SA accepted the facility's Plan of Correction (POC) on 07/22/24 at 7:40 PM. After completing observations, record reviews, and staff interviews regarding the implementation of the POC the IJ was abated at 07/23/24 at 2:30 pm. [...]

Inspectors wroteBased on resident and staff interview and record review, the facility failed to provide showers and/or bed baths in accordance with the residents' preference and/or plan of care. Residents stated the staff preferred to give them bed/sponge baths, rather than a shower, because it is less work. This was true for three (3) of six (6) residents reviewed for the care area of choices and for five (5) of seven (7) residents reviewed for the care area of Activities of Daily Living (ADL) during the long-term care survey process. For Resident #42 the facility failed to provide a timely transfer from her chair to her bed causing the resident to become agitated and cry out for a period of 30 minutes. This resulted in actual psychosocial harm for Resident #42. Resident # 42 was a random opportunity for discovery. Resident Identifiers: #48, #40, #3, #51, #65, #22, #60, #63 and #42. Facility census: [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program for disposal of soiled linen, not wearing proper personal protective equipment (PPE) in enhanced barrier precaution (EBP) rooms, storage of used bedpans, placing a dirty dinner tray on the cart of clean trays and disposal of soiled gloves. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 71.

Inspectors wroteBased on record review, staff interview and resident interview the facility failed to honor residents' preference for bed bath/showers. This failed practice was found true for five (5) of (7) seven residents reviewed for the care area of choices during the Long-Term Care Survey Process. Resident identifiers: #60, #63, #40, #3 and #48. Facility Census: 71.

Inspectors wroteBased on observations and staff interviews the facility failed to keep residents' medical information confidential. Facility staff left a laptop open with resident information which was visible to the public. This was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long-Term Care facility.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to provide a comfortable, homelike environment for residents residing in room [ROOM NUMBER], #202, #203, #303, #306, #309, #310, #312, #402, #404, #407, #408, #409, #410 and the slats of the packaged terminal air conditioner (PTAC) in Resident #60's room. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Facility Census: 71.

Inspectors wroteBased on record review and staff interview the facility failed to develop and/or implement care plans related to Dementia, Anxiety, Dialysis and showers. This failed practice was found true for seven (7) of 34 residents reviewed for care plan accuracy and implementation during the Long-Term Care Survey Process. Resident identifiers: #54, #22, #65, #51, #61, #9 and #71. Facility Census 71.

Inspectors wroteBased on observation, policy review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing at the facility. Facility Census: 71. Findings Include: a) Treatment Cart On 07/22/24 at 12:50 PM, an observation found an unlocked, unattended treatment cart in the resident tv room. The cart was in a place which was easily accessible allowing access to these medication/treatment supplies by residents, unauthorized persons, or visitors. On 07/22/24 at 1:42 PM, during an interview with Registered Nurse (RN) #21, it was confirmand the Treatment cart was unlocked. RN #21 verified the treatment cart should not be unlocked when unattended. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to conduct yearly performance evaluations for each Nurse Aide. This was true for three (3) out of five (5) Nurse Aides reviewed during the survey process. Staff identifiers: NA #34, NA #63, NA# 61. Facility census: 71.

Inspectors wroteBased on record review and staff interview the facility failed to do behavior and side effect monitoring for psychotropic medications. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #54. Facility Census 71.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to record temperatures for the medication refrigerator. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 71. Findings Include: On 07/25/24 at 9:25 AM, the medication room was observed. The observation found the medication refrigerator temperatures were not completed for March 2024 through July 2024. The following dates were not completed: [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure food was discarded after the expiration date. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census 71.

Inspectors wroteBased on observation, and staff interview, the facility failed to ensure the resident call system was functioning as designed. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 71.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the State ombudsman of a discharge for Resident #71. This was true for one (1) of two (2) residents reviewed under the care area of discharges. Resident identifier: 71. Facility Census: 71. Findings Include: a) Resident #71 On 07/23/24 at 9:45 AM, a record review was completed for Resident #71. The review found the resident had been discharged to another facility on 05/09/24. However, the facility could not provide evidence of the notification of discharge was sent to the State ombudsman. On 07/23/24 at 1:00 PM, the Administrator was notified and stated, We do not have the notification to the Ombudsman regarding the discharge.

Inspectors wroteBased on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) regarding the discharge destination for Resident #71 and #72. This was true for two (2) of two (2) residents reviewed under the care area of discharges. Resident identifiers: #71 and #72. Facility Census: 71.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #9's care plan was revised when the status of her pressure ulcer changed. This was true for one (1) of 34 sampled residents reviewed during the long term care survey process. Resident Identifier: #42. Facility Census: 71. Findings Include: a) Resident #42 A record review on 07/23/23 at 9:48 AM revealed an order for Resident #42 which read as follows: Cleanse Stage IV to right heel with wound cleanser and pat dry. Apply Calc alginate and cover with opti-foam heel protection every day. Every day shift. Further record review showed a care plan for a Pressure Ulcer to the right heel staged as a stage 2 (two) pressure ulcer. The skin and wound evaluation effective 07/22/24 has the Pressure Ulcer to the right heal as an unstageable pressure ulcer. [...]

Inspectors wroteBased on observation, record review, and staff interview the facility failed to provide an activity program to meet the needs and interest of the residents and failed to provide scheduled one-to-one visits for residents. This failed practice was found true for (1) one of (6) six residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #27. Facility Census 71.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide services and/or treatment to Resident #64 to prevent reduction in range of motion. This was true for one (1) of four (4) residents reviewed for limited range of motion during the survey process. Resident identifier: 64. Facility census: 71.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to have sufficient staff to provide care for residents at the facility. This has the potential to affect all residents currently residing at the facility. Resident identifier: #64. Facility census: 71.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to accurately document the dental condition of Resident #227 on the admission assessment. This was a random opportunity for discovery. Resident identifier: #227. Facility census: 71.

Inspectors wroteBased on deficiencies cited, resident interviews, resident representative interview, review of resident council minutes, resident council member interviews, review of the facility assessment, and facility staffing details, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. This failed practice had the potential to affect all residents currently residing in the facility. Facility census: 74. Findings Included: a) Citations During the facility's long-term care survey relevant citations included: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least eight (8) consecutive hours a day, seven (7) days a week. This was true for one (1) of six (6) randomly sampled dates from July 2022 - October 2022. This had the potential to affect all residents who currently reside at the facility. Facility census: 74.

Inspectors wroteBased on facility documentation and staff interview the facility failed to Inform residents, their representatives, and families of those residing in facilities by 5 PM the next calendar day following the occurrence of a confirmed infection of COVID-19. This failed practice had the potential to affect all residents in the facility. Facility Census: 74.

Inspectors wroteBased on observation, record review, resident interview, staff interview and facility documentation review facility failed to provide a resident transportation to a scheduled outside medical appointment. The facility failed to provide one (1) of two (2) residents reviewed for dialysis with transportation services to dialysis. The facility failed to obtain a physician order for a fall mat in place for one (1) of six (6) residents reviewed for falls. Resident identifiers: # 30, #33 and # 34. Facility census: 74.

Inspectors wroteBased on observation and staff Interview, the facility failed to ensure the facility was free from accident hazards in which it had control. Two (2) medication carts and one (1) treatment cart were left unlocked and unattended, allowing access to medications by residents and unauthorized persons. Additionally, the facility failed to lock and secure chemicals / disinfectant supplies. These were random opportunities for discovery and had the potential to effect more than a limited number of residents. Facility Census: 74.

Inspectors wroteBased on medical record review and staff interview the facility failed to assess resident's conditions and monitor for complications before and after dialysis treatments. This was true for two (2) of two (2) residents reviewed for dialysis treatment during the Long-Term Care Survey Process (LTCSP). Resident Identifiers #47 and #30. Facility census 74. Findings Included: a) Resident #47 Medical record review of resident #47s chart revealed there were no pre and post dialysis assessments completed in resident's active chart. Continued review found a physician's order: Dialysis center every Monday, Wednesday, and Friday with chair time at 11:30 am. On 09/27/22 at 12:58 PM the facility staff were unable to locate Resident #47s dialysis communication book. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to post the daily nurse staffing. This was a random opportunity for discovery. Facility census 74.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to provide routine and emergency drugs and biologicals to its residents as prescribed. This is true for 2 of 3 residents reviewed during medication administration. Resident identifiers: #120 and #62. Facility census: 74.

Inspectors wroteBased on observation, food temperature checks, record review and staff interview the facility failed to ensure sufficient staff were employed to carry out the functions of the food and nutrition services in accordance with the facility assessment. These were random opportunities for discovery. The failed practice had the potential to affect more than a limited number of residents. Facility census: 74.

Inspectors wroteBased on resident interview, staff interview, facility documentation, and resident council minutes the facility failed to provide food in the amount for resident needs and preference. This affected [NAME] than a limited number of residents during the Long-Term Care Survey Process (LTCSP). Resident identifier #46. Facility census: 74.

Inspectors wroteBased on resident interviews, observation and staff interviews the facility failed to serve food at an appetizing and preferable temperature. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74.

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure meals were served at times in accordance with resident's needs, preferences, and requests. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the temperature logs were complete and up to date for the walk- in refrigerator, walk-in freezer, free standing refrigerator, and dish machine. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of residents. Facility census: 74.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the required thoroughness of the facility assessment to include the Dietary Manager as it related to food and nutritional services. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of Residents. Facility census: 74.

Inspectors wroteBased on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The nurse failed to use a barrier during medication pass and touched the residents pills with her bare hands during medication prep. This was a random opportunity for discovery and was true for Resident #121. Resident identifier: #121. Facility census: 74.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure each resident had the opportunity to exercise autonomy regarding preferences that were important to their life. The facility failed to honor a resident's preference to receive a shower in the morning. This was true for one (1) of 18 residents reviewed during the annual long-term care survey process. Resident identifier #64. Facility census: 74.

Inspectors wroteBased on record review and staff interview, the facility failed implement written abuse and neglect policies and procedures for reporting in order to prevent all types of abuse. The facility failed to report an incident of neglect/mistreatment with Resident #221. This practice affected one (1) of two (2) residents reviewed using the abuse pathway in the survey process. Resident identifier: #221. Facility census: 74.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury and an allegation of neglect/mistreatment by staff, were reported in a timely manner to the appropriate state agencies. The failure to make a timely report was true for one (1) of five (5) sampled residents for falls and was true for one (1) of two (2) residents reviewed for abuse. Resident identifiers: #66 and #221. Facility census: 74.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete accurate Minimum Data Set (MDS) assessments for one (1) of 18 assessments reviewed during the Long-Term Care Survey Process (LTCSP). The MDS assessment for Resident #72 did not accurately reflect the resident's discharge status. Resident identifier: #72. Facility census: 74.

Inspectors wroteBased on medical record review and interview, the facility failed to revise person-centered comprehensive care plans for Resident #68's nutritional services and Resident #4's area of smoking. This practice affected two (2) of 18 Resident care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was reviewed and revised for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers #68 and #4. Facility census: 74.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure there was a current physician order to administer oxygen to a resident. This was a random opportunity for discovery. Resident identifier: #38. Facility census: 74.

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to ensure pain medications were administered in accordance with professional standards of practice. The failed practice was true for one (1) of four (4) Residents reviewed for pain. Resident identifier: #38. Facility census: 74.