Shenandoah Senior Living Community

Inspectors wroteBased on a review of select facility policy, observations, and resident and staff interviews, it was determined the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for four residents of 24 residents observed for the presence of drinking water. (Residents 1,2,3,4).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined the facility failed to consistently implement person-centered care plan interventions for pressure injury prevention for one of 24 residents reviewed (Resident 2).

Inspectors wroteBased on clinical record review, select facility policy review, and resident and staff interviews, it was determined the facility failed to ensure that pain management was provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of 24 residents reviewed (Resident 80).

Inspectors wroteBased on a review of clinical records, select facility policy, investigative documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to maintain a safe and homelike environment by not ensuring a bathroom safety handrail (grab bar) was securely affixed to the wall for one resident out of 24 residents reviewed (Resident 31).

Inspectors wroteBased on clinical record review, select facility policy review, investigative documentation provided by the facility, and staff interviews, it was determined the facility displayed past noncompliance by failing to ensure the safety and supervision of one resident from exiting through unsecured doors for one out of 24 residents reviewed (Resident 99).

Inspectors wroteBased on observation, clinical record review, select facility policy review, and staff interviews, it was determined the facility failed to ensure that appropriate physician orders, a documented medical justification, and an individualized plan of care were in place for the use and management of an indwelling urinary catheter for one of 24 residents reviewed (Resident 83).

Inspectors wroteBased on a review of controlled drug shift count records, clinical records, facility policy, and staff interviews, it was determined the facility failed to implement procedures to ensure accurate accountability and documentation of controlled medications on three of four medication carts observed and failed to maintain accurate records related to the administration and reconciliation of controlled medications for one of 24 residents reviewed (Resident 80).

Inspectors wroteBased on clinical record review, consultant pharmacist documentation review, and staff interview, it was determined the facility failed to ensure the attending physician responded to and acted upon consultant pharmacist recommendations regarding identified irregularities in the medication regimen for one of 24 residents reviewed (Resident 13).

Inspectors wroteBased on a review of select facility policies, clinical records, and staff and resident interviews, it was determined that the facility failed to ensure an ongoing grievance system was maintained to track resident grievances, including the date and time the grievance was lodged and the date of resolution, for one of 24 residents reviewed (Resident 103).

Inspectors wroteBased on a review of clinical records, select facility investigative documentation, facility policies, American Heart Association (AHA) guidelines, facility-provided witness statements, and staff interviews, it was determined that the facility failed to ensure that cardiopulmonary resuscitation (CPR) was initiated for a resident in accordance with the resident's advance directives and nationally recognized standards of practice. This failure placed one of 10 residents sampled (Resident CR1) and 47 other residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, and 47) who desired CPR, out of the facility's 101 resident census, in Immediate Jeopardy to their health and safety with the potential for death as a result of a similar occurrence.

Inspectors wroteBased on a review of clinical records, select facility policies, applicable state professional nursing standards, and staff interviews, it was determined the facility failed to provide nursing services in accordance with professional standards of practice, resulting in actual harm. Specifically, the facility failed to initiate cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure consisting of chest compressions and rescue breathing used when an individual is found unresponsive and not breathing normally) for one out of 10 residents reviewed (Resident CR1) who had documented wishes for Full Code status (meaning the resident wanted all possible life-saving measures, including CPR, if their heart or breathing stopped). [...]

Inspectors wroteBased on a review of clinical records, facility policies and procedures, facility-provided investigative documentation, job descriptions, witness statements, and staff interviews, it was determined that the facility failed to administer the facility in compliance with federal requirements to ensure resident health and safety. Specifically, the Administrator and Director of Nursing failed to establish, implement, oversee, and enforce an effective cardiopulmonary resuscitation (CPR) system, resulting in licensed nursing staff not initiating CPR for one resident (Resident CR1) out of 10 residents sampled who desired full resuscitative measures and did not exhibit documented irreversible signs of death. This failure resulted in Immediate Jeopardy.

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders were consistent in reflecting a resident's elected code status for two of 23 residents reviewed (Residents 29 and 80).

Inspectors wroteBased on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined the facility failed to ensure the provision of care and services necessary to prevent a fall and maintain the physical health of one resident out of 23 residents reviewed (Resident 30).

Inspectors wroteBased on the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interview, it was determined the facility failed to timely report an instance of resident neglect to the State Survey Agency for one out of the 23 residents reviewed (Resident 30).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for 2 residents out of 23 residents sampled (Resident 56 and 80). According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. [...]

Inspectors wroteBased on review of select facility policy, employee files, and staff interview it was determined that the facility failed to timely train one agency employee out of four employees reviewed on the facility's abuse prohibition policy and procedures.

Inspectors wroteBased on review of select facility policy and controlled drug records, observation, and staff interview, it was determined the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on two of three medication carts reviewed (A, and C hall).

Inspectors wroteBased on review of clinical records, information submitted by the facility, select facility reports, and staff interviews it was determined the facility failed to provide a resident who sustained repeated falls the necessary supervision and/or effective fall interventions to prevent a fall with a monor injury for one out of five sampled residents for accidents (Resident 7).

Inspectors wroteBased on observation, a review of clinical records, a review of nurse staffing, and interviews with staff and residents, it was determined the facility failed to provide sufficient nursing staff to provide timely and quality care for residents that sustained falls, for three residents out of 20 sampled (Residents 7, 70, and 90) and failed to provide timely care expressed by residents during a resident group interview (Residents 1, 35, 52, 65, and 71).

Inspectors wroteBased on clinical record review, observations, and staff interview, it was determined the facility failed to maintain infection control practices to prevent potential spread of infection for two out of 20 residents sampled (Resident 77 and 83) and failed to offer and/or provide SARS-CoV-2 (COVID-19) immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to one of five residents reviewed (Resident 2).

Inspectors wroteBased on observations and resident and staff interviews it was determined the facility failed to accommodate residents' need and preference for access to the call bell system in order to request staff assistance for one resident (Resident 79).

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 20 sampled (Residents 95).

Inspectors wroteBased on observation, clinical record review, facility investigation reports, and staff interviews, it was determined the facility failed to develop and implement a person-centered care plan to meet the specific needs of one resident out of 20 sampled (Resident 70). Findings including: A clinical record review revealed Resident 70 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Resident 70 has a documented history of falls, as noted in facility investigations and a clinical record review, occurring on the following dates: February 24, March 2, March 29, and June 2, 2024. [...]

Inspectors wroteBased on review of clinical records and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of one of the 20 residents sampled (Resident 77).

Inspectors wroteBased on review of select facility policy, clinical records and staff interview, it was determined the facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for a resident with an identified significant weight loss and gain for 1 of 20 residents sampled (Resident 31).

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to ensure the resident's drug regimen was free of unnecessary antibiotic medication for one out of 20 residents sampled (Resident 2).

Inspectors wroteBased on review of employee personnel records and staff interview, it was determined the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Findings Include: A review of facility policy review and observations determined the facility failed to ensure infection control practices were maintained to prevent the spread of infection as evidenced by the transmission of the COVID-19 virus between two residents on September 5, 2024. During an interview on September 13, 2024, at approximately 10:30 AM the Nursing Home Administrator (NHA) confirmed that the facility did not currently have an infection preventionist. The NHA explained that the Director of Nursing (DON) has been covering the duties of the infection preventionist since July 18, 2024. [...]

Inspectors wroteBased on review clinical records and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for staff assistance as evidenced by experiences reported by six residents out of eight interviewed (Residents 21, 62, 81, 39, 49, 69, 101, and 61).

Inspectors wroteBased on observation, a review of select facility policy, clinical records, the minutes from resident group meetings and grievances lodged with the facility, and resident and staff interviews, it was determined that the facility failed to demonstrate their response to resident complaints and grievances, including those raised at group meetings, including resident complaints and grievances raised during two of the two resident group meeting minutes reviewed (March 2024 and April 2024)

Inspectors wroteBased on resident and staff interviews and a review of temperature logs and clinical records revealed that the facility failed to serve appetizing food at palatable temperatures as discerned by residents including five of eight residents interviewed (Resident 21, 101, 61, 81, and 69).

Inspectors wroteBased on a review of clinical records and the facility's grievance/concern log, staff and resident interviews it was determined that the facility failed to demonstrate prompt efforts to resolve resident grievances as evidenced by one resident out of eight sampled (Resident 69) and maintain accurate and complete evidence of the implementation of the facility's grievance process from receipt to resolution.

Inspectors wroteBased on a review of clinical records, information submitted by the facility, and select facility reports, and staff interviews, it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor the whereabouts and activities of one resident out of the 13 sampled (Resident CR1).

Inspectors wroteBased on review of clinical records, facility contracts and select policies and procedures and interview with facility staff, it was determined that the facility failed to provide residents with timely intravenous fluids as prescribed and consistent with professional standards of practice for one resident (Resident C1) out of eight residents reviewed.

Inspectors wroteBased on a review of clinical records and select investigation reports and staff interview, it was determined that the facility failed to develop and consistently implement a person-centered care plan to address a resident's known risk factors for falls for one resident out of 11 sampled.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to timely identify and address a resident's decline in food and fluid consumption with significant weight loss for one resident out of eight sampled.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to timely obtain prescribed laboratory services for one resident out of eight residents sampled (Resident C1).

Inspectors wroteBased on review of the facility's abuse prohibition policy and procedures, clinical records, and select investigative reports and staff interview it was determined that the facility neglected to provide care and services necessary to avoid physical harm, a fractured hip and a fractured ankle, and maintain physical health of two residents out of eight residents sampled (Residents CR1 and 2).

Inspectors wroteBased on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to consistently provide restorative nursing services as planned to maintain mobility, range of motion and to ensure the application of splinting devices for three residents of 20 sampled (Residents 1, 27, and 54).

Inspectors wroteBased on review of clinical records, information submitted by the facility, and select facility reports and staff interviews it was determined that the facility failed to provide effective safety measures planned to prevent falls for one resident out of four reviewed for falls (Resident 82).